The Big Budget Bill, One Year Later: Millions Lose Coverage, Millions More Remain at Risk  

One year ago, President Trump signed his big budget bill (H.R. 1) that slashed more than $1 trillion in health care to pay for permanent tax cuts to the wealthiest Americans and largest corporations. The President and Republican Congressional leaders called it the “big beautiful bill.” The millions of people who saw the harm to their health coverage, care, and costs may have different words for it.

Twelve months later, we are starting to see the impacts — services being scaled back and closed, premiums doubling, and millions of people falling off coverage, becoming uninsured, or underinsured. And it’s only going to get worse.

Thanks to the decisions the Trump administration has made since, the catastrophic consequences are likely to be worse than predicted. At nearly every turn, the administration has used implementation to make bigger cuts to care, restricting access to coverage in ways that go beyond the law. To be clear, H.R. 1 enacted the worst health care cuts in history, but the administration is making deliberate decisions to make the ramifications of the law even worse.

Cutting $900 Billion in Medicaid Means Kicking Millions Off Coverage, and More

Congressional Republicans insisted throughout the H.R. 1 debate that the bill would not kick eligible enrollees off their health coverage, and that they would especially take measures to not harm vulnerable people — or as Speaker Mike Johnson said, that millions of Medicaid enrollees would not lose their coverage unless they “choose to do so.” Dubious at the time, that claim doesn’t hold water a year later.

The math is simple: you can’t cut $1 trillion from Medicaid without cutting coverage for people who need it. H.R. 1 gets there through two mechanisms. First, new eligibility requirements — chiefly work reporting requirements, but also forcing Americans to reapply every six months, and more — designed to create enough bureaucratic burdens so that eligible people lose coverage anyway. Second, restrictions on how states finance their Medicaid programs, which shrink the overall pie regardless of who technically qualifies.

Work reporting requirements are the centerpiece. Beginning January 1, 2027, adults enrolled in Medicaid expansion must document at least 80 hours per month of employment or qualifying activities — or prove they meet an exemption. While more than 90% of adults on Medicaid are already working or would qualify for an exemption, the new requirements set a paperwork trap. The issue is less whether they are working, but rather can they navigate a bureaucratic system designed to be difficult — and history tells us many won’t. States that have tried similar requirements saw the same outcome: eligible people lost coverage not because they were ineligible, but because they couldn’t manage the documentation. Employment rates didn’t move. Administrative costs soared. And Americans lost access to care.

The Urban Institute projected between 4.9 and 10.1 million people could lose Medicaid coverage by 2028 because of these bureaucratic barriers alone. However, those numbers assumed states would have some flexibility in implementing these requirements, including using the power of electronic databases to streamline the process. That was before the Trump Administration’s June 2026 interim final rule was released, which eliminated much of that flexibility — and made a complex process exponentially more complicated. The rule effectively bans states from allowing people to self-report their medical circumstances after 2027, a direct blow to the most vulnerable enrollees: people without regular access to providers, people seeking treatment outside traditional health care settings, people who don’t have formal documentation of conditions they’re living with every day.

Now, the new federal rule requires proof not just of a medical condition, but that the condition prevents the ability to work consistently or participate in other activities — a further restriction that may deter working at all for fear of losing medical frailty status. This radical redefinition of “medical frailty” is a much higher threshold — requiring not just a diagnostic code, but likely also a doctor’s visit, based on clinical conditions that are constantly changing. Imagine the burden on not just patients but the whole health system to accommodate millions more doctor’s notes. What was complicated is now Kafkaesque. Suddenly, a cancer patient doesn’t know if the requirement applies. What might have been verified with a diagnostic code showing the patient’s rounds of chemotherapy now requires more unnecessary doctor visits to keep their coverage and treatment.

States Are Already Paying — And So Are Patients

The cuts don’t fully take effect until 2027, but states are already absorbing the fiscal shock. Beyond the bureaucratic barriers and coverage loss, H.R. 1 restricts how states finance Medicaid — capping state directed payments that boost reimbursement for safety-net providers, and narrowing states’ ability to structure provider taxes. An estimated $149 billion in federal Medicaid spending will be lost over the next decade through state-directed payment cuts alone, forcing at least 29 states to slash what they pay providers. Fewer provider payments means fewer providers willing to see Medicaid patients — which means less access to care whether or not coverage technically exists on paper.

With less federal support, states face impossible choices. Kentucky has already allocated $691 million less to Medicaid over two years than its own state agency said was needed. That shortfall doesn’t disappear — it shows up as longer wait times, fewer services, and providers who can no longer afford to keep their doors open to low-income patients.

Patients Priced and Pushed Out of Individual ACA Marketplace Coverage

H.R. 1’s damage to Medicaid is the headline, but the damage done to health care access by the Trump administration extends to health coverage both public and private. Millions of Americans who buy coverage through the Affordable Care Act (ACA) Marketplace have seen their premiums skyrocket, dropped down to lower-level coverage plans, or left the marketplaces altogether. Despite bipartisan majorities in both chambers of Congress supporting an extension of the enhanced premium tax credits that made coverage affordable for more than 22 million people, the Trump administration and Republican-controlled Congress allowed them to expire. Advocates warned this would be catastrophic for marketplace enrollees, with estimates that 5.5 million people would eventually lose coverage as these impacts snowball.

Just last week, the Department of Health and Human Services (HHS) released 2026 enrollment data showing that nearly four million people have already dropped coverage since January, and more than five million people have lost ACA coverage since the start of the Trump administration. HHS claimed this reduction in coverage is due to eliminating fraudulent “phantom enrollments” — an insult to the real people impacted by the premium spikes and who became uninsured or underinsured.

For many who remain in the individual market, their coverage may soon look worse. The 2027 payment rule expands access to “catastrophic” plans with deductibles as high as nearly $30,000, allows plans with no provider networks to be sold on the Marketplace, and restricts states from requiring coverage of essential services. The trend is clear: the administration’s answer to unaffordable premiums is to let insurers sell more expensive plans that cover less.

The Fight Ahead

A year ago, health advocates warned what would happen: coverage losses, premium and out-of-pocket cost spikes, and administrative chaos. What we have seen so far surpassed even the worst expectations. The administration has used their regulatory and executive powers to further restrict care and make coverage harder to afford.

However, these impacts are not inevitable. State officials are limited but are trying to find ways to backfill the worst of the cuts and put in place patient protections. Lawsuits are pushing back where the administration is going beyond the law — and often winning, albeit on a slower timeframe. Consumer and community advocates are filing comments and actively working on the details of implementation decisions, both to mitigate and document the damage.

One year in, tens of millions of Americans are paying the price. With our partners, Families USA is tracking the damage in real time — every state budget, every regulation, every enrollment drop. We need the stories of those impacted, whether losing coverage or a community service. Every Congressmember who voted for H.R.1 a year ago should be held accountable — they were warned of the consequence. Our work is to make clear the consequences, so the next Congress has a mandate and movement to not just repeal these cuts but to reorient and strengthen our health system in a new direction.