Dissecting the Deepest Cuts: New Expenses for Adults on Medicaid

The 2025 budget reconciliation law (H.R. 1) imposes major new restrictions that will make it significantly more difficult for eligible adults to enroll in the Affordable Care Act’s (ACA’s) Medicaid expansion and, once enrolled, to access the health services they need. One new requirement is for states to impose mandatory cost sharing for ACA Medicaid expansion adults, obligating enrollees to pay copays and other out-of-pocket expenses in order to receive health care services; this change is estimated to cause a $7.4 billion cut to Medicaid beneficiary care over 10 years. Below is a detailed explanation of Medicaid cost sharing and the implications of H.R. 1’s cost sharing mandate on consumers, health care providers and state Medicaid programs. A companion explainer examines new eligibility hurdles for adults in the ACA expansion, including strict work mandates and more frequent eligibility checks.