What’s in the ‘Big, Beautiful Bill’—and what was left out?
A day after it passed both houses of Congress, a massive budget reconciliation bill was signed into law by President Donald Trump, setting in motion multiple provisions that will directly impact healthcare funding and patient care delivery.
On July 4, the President made what’s being referred to as the “One Big, Beautiful Bill Act” official during a ceremony on the White House lawn. The 940-page document has changed rapidly as it went back and forth between the U.S. House of Representatives and Senate this year, but the final wording contains carve-outs to fund space travel and a massive $150 billion increase to defense spending.
A key focus of the Trump administration has been tax cut provisions, which include an increase in state and local deductions, an end to taxes on Social Security and tipped wages, along with broad cuts to payroll tax rates. In large part, it’s an extension of what was seen in 2017 tax policy passed during Trump’s first term.
Cuts aplenty to social safety net
For healthcare, the bill contained some major indirect and direct changes that will impact hospitals, health systems and Medicaid beneficiaries over the next few years. Here is a summary:
- An end to COVID-era subsidies for plans sold on the Affordable Care Act’s healthcare.gov marketplace. Further, bridge coverage designed to allow for late enrollment based on a medical diagnosis, or as a result of job loss, will no longer be available starting next year.
- Legal immigrants—those in the country on a visa or Green Card—will no longer be eligible for health coverage sold through the federal marketplace.
- A roughly 20% cut to Medicaid funding, meaning states will have to cover more of the cost of the program. These cuts happen gradually through 2034, adding up to $1 trillion, according to an analysis from Axios.
- Medicaid funding is also tied to a work requirement, where beneficiaries will need to remain employed or volunteer a certain number of hours each month to maintain their coverage.
- Reduced spending for the Supplemental Nutrition Assistance Program (SNAP)—federal funding used to supply food for lower-income families. Similarly, money used to provide free meals to students at school has also been slashed.
President Trump stated on numerous occasions he opposed cuts to Medicaid. However, he ultimately chose to sign the bill on Independence Day. Per the terms, most cuts to SNAP and Medicaid will not begin until after midterm elections in 2026.
Experts weigh in on ‘Big’ impact
The direct impact of all the above on healthcare systems and providers remains to be seen. However, a report from the Commonwealth Fund and George Mason University released in May found the trickle-down effects of cuts to the social safety net could result in 1 million lost jobs by 2026—477,000 of which could be from healthcare alone, as people lose coverage and providers, in turn, see a drop in revenue.
Another report, this time from the Chartis Center for Rural Health, raised fears that cuts to Medicaid could force dozens of rural hospitals to close their doors, while others may cut services like maternity care to stay afloat.
Approval for the bill has been lagging, even among Republicans. Quinnipiac polling from June found that 55% of voters opposed the bill, while only 29% expressed support. Similarly, Pew Research polling revealed that 49% of all Americans opposed passage of the One Big, Beautiful Bill, while only 29% supported it.
Proposed moratorium on AI regulations removed
A controversial provision in the legislation that would have banned states from regulating artificial intelligence for a decade was pulled out by the Senate and did not make it into the final wording. For now, states are still free to regulate AI technologies, including those for healthcare, in accordance with the law.
The full text of the One Big, Beautiful Bill Act is available here.
Chad is an award-winning writer and editor with over 15 years of experience working in media. He has a decade-long professional background in healthcare, working as a writer and in public relations.