Known as the “One Big Beautiful Bill Act,” the legislation represents the most sweeping overhaul of Medicaid in decades. Passed in the House and now under Senate review, the bill would require all states to enforce new rules mandating that able-bodied adults work at least 80 hours per month or enroll in job training programs to keep their coverage. It also imposes semiannual income eligibility checks, doubling the paperwork for those trying to retain health benefits.
This effort to overhaul Medicaid strikes at the heart of a program that has long served as a safety net for low-income Americans. Medicaid is a joint federal and state program that provides free or low-cost health coverage to more than 87 million people across the country. It covers children, pregnant women, seniors, people with disabilities, and low-income adults, many of whom would otherwise go without basic care.
According to the Congressional Budget Office (CBO), the proposed changes could result in up to 8.6 million people losing Medicaid coverage—not necessarily because they’re ineligible, but because of the complexity of the new requirements and frequent re-verification.
Who’s Most at Risk?
Health policy experts say the bill would disproportionately affect:
- Low-wage and gig workers with inconsistent hours, who may not consistently meet the 80-hour-per-month threshold.
- Undocumented immigrants, whose care is often funded through local programs that would lose federal support.
- Seniors and individuals with disabilities, who may not be able to meet work requirements or navigate the added red tape.
- Unpaid family caregivers, many of whom stay home to care for children or aging relatives without compensation.
- People in rural and underserved areas, where access to jobs and digital infrastructure is limited.
Critics say these changes are not about reducing fraud, but about pushing people off the rolls through bureaucratic pressure.
D.C. Illustrates the National Stakes
In Washington, D.C., the potential impact offers a case study of the national threat. The city already faces a $580 million Medicaid shortfall and would need to come up with another $715 million to continue its Healthcare Alliance Program, which provides care to over 27,000 undocumented and low-income residents.
Trump’s Argument: Accountability and Cost Control
Former President Donald Trump, who has made support for the bill part of his 2025 platform, defended the changes as a step toward restoring fiscal responsibility.
“Too many people are on Medicaid who shouldn’t be,” he said at a recent event. “We want to help those in real need—not those who choose not to work.”
Supporters of the bill argue it will curb dependency and make Medicaid more efficient. But studies have shown that most working-age Medicaid recipients already have jobs, and past state-level experiments with work requirements—such as in Arkansas—caused thousands to lose coverage due to missed deadlines and confusing rules, not fraud.
The Senate Holds the Final Say
As of May 26, the bill is awaiting action in the U.S. Senate, where several lawmakers have expressed concerns about its unintended consequences. Advocates warn that if passed, the bill could dismantle one of the country’s core public health pillars—with fallout felt in every state.
For those relying on Medicaid, the uncertainty is growing. From pharmacies to emergency rooms, from small towns to major cities—the future of American healthcare access is now on the line.
