President Donald Trump signed the One Big Beautiful Bill Act on July 4 after the Republican-led House passed it on July 3 in a 218-214 vote.
Republican Reps. Thomas Massie of Kentucky and Brian Fitzpatrick of Pennsylvania voted against the legislation, NBC News reported.
“[It] was the Senate’s amendments to Medicaid, in addition to several other Senate provisions, that altered the analysis for our PA-1 community,” Mr. Fitzpatrick said in a July 3 news release. “The original House language was written in a way that protected our community; the Senate amendments fell short of our standard.”
The news comes after the revised 887-page version of the legislation passed the Republican-led Senate on July 1 in a 51-50 vote, with Vice President JD Vance delivering the tie-breaking vote in favor of the bill.
The vote followed a nearly 24 hour “vote-a-rama” that began June 30, during which lawmakers could propose an unlimited number of amendments to vote on regarding an earlier version of the bill.
Here are nine things to know:
1. Over the next decade, the legislation would cause revenues to decrease by around $4.5 trillion and lead to $1.2 trillion in reduced spending — increasing the national debt by $3.3 trillion, per the Congressional Budget Office. Medicaid spending would decrease by nearly $1 trillion, and the number of uninsured individuals would grow 11.8 million more by 2034.
2. The revised bill includes $50 billion over five years for the Rural Health Transformation program, which aims to support rural healthcare systems. The funds will be administered by CMS and will allocate $10 billion annually from fiscal year 2026 to 2030.
3. The bill restricts ACA premium tax credits eligibility, prohibiting access for people ineligible for Medicaid due to immigration status and limiting special enrollment period credits unless certain conditions are met. Oversight is also tightened by requiring eligibility verification prior to credits being issued and it removes current caps on how much the government is allowed to reclaim from those who receive excess advance payments.
4. States would have to establish Medicaid work requirements for certain individuals, starting as early as January 2027. Individuals would need to work at least 80 hours, complete community service, participate in a work program, or enroll in an educational program for a set number of hours each month. States will set specific requirements, such as the number of consecutive months or the frequency of engagement checks, and exceptions would apply.
5. Federal oversight of Medicaid provider taxes would be tightened by imposing stricter criteria for states seeking uniform tax requirement waivers, with the aim of ensuring a more standardized application across state programs.
6. Enhanced Federal Medical Assistance Percentage incentives that are connected to provider taxes would be phased out under the bill, which could potentially reduce federal matching funds for states with reliance on such financing methods. State-directed payments under Medicaid managed care will also see new limits, which narrow ways that states can secure and redistribute collected provider tax revenues. Additionally, a 3.5% cap on provider taxes would be applied, impacting state-directed payments like the Healthcare Access and Stabilization Program.
7. The bill includes a temporary 2.5% increase to the Medicare Physician Fee Schedule for 2026 for exceptional circumstances.
8. The bill has dropped a proposed ban on Medicaid and CHIP funding for gender-transition procedures.
9. The legislation has received criticism from many healthcare organizations.
Bobby Mukkamala, MD, president, American Medical Association: Today is a sad and unnecessarily harmful day for patients and health care across the country, and its impact will reverberate for years. Care will be less accessible and patients may simply forego seeing their physician because the lifelines of Medicaid and CHIP are severed.
This is bad for my patients in Flint, Michigan, and it is devastating for the estimated 11.8 million people who will have no health insurance coverage as a result of this bill.
The American Medical Association’s mission is promoting the art and science of medicine and the betterment of public health. This bill moves us in the wrong direction. It will make it harder to access care and make patients sicker. It will make it more likely that acute, treatable illnesses will turn into life-threatening or costly chronic conditions. That is disappointing, maddening, and unacceptable.
Bruce Siegel, MD, president and CEO, America’s Essential Hospitals: Passage of this misguided bill has unleashed chaos on the U.S. health care system, and the dire consequences will be felt for quite some time. Millions of Americans will see their health care coverage vanish through burdensome Medicaid work requirements and other eligibility changes throughout the bill. Hospitals across the country have been destabilized, affecting their ability to serve patients and their communities. We are in a crisis. The bill’s restrictions on state directed payments and provider taxes cut off critical financial lifelines for hospitals, and at the same time millions of Americans will lose their Medicaid coverage. Widespread coverage losses plus weakened hospitals is a recipe for disaster, and patients will pay the price.
The cuts will add $443.4 billion to hospitals’ uncompensated care costs from 2025 to 2034. State directed payments are a critical source of support for hospitals, particularly in rural areas, and provider taxes help reduce the gap between Medicaid and other payers, ensuring that physicians can take Medicaid patients and hospitals can be adequately staffed. Cutting these lifelines is not sustainable, and it will harm patients. We will continue to work with lawmakers to find positive solutions to sustain and strengthen Medicaid and keep our hospitals open. Now more than ever, our hospitals truly are essential.
Chip Kahn, president and CEO, Federation of American Hospitals: It cannot be overstated – the health cuts passed by Congress today represent the largest cuts to care our country has ever seen. Americans will feel the reverberations of this legislation in communities across the nation – whether directly due to a loss of coverage, the increase of their costs, or as doctors and hospitals scramble to sustain services and keep their doors open.
Members of Congress will have to revisit this calamity to mitigate the effects on their constituents and communities. It’s mission critical that they start by extending the soon-to-expire enhanced tax credits, which are lifelines for the Americans who depend on the marketplace for their health coverage. Time is of the essence. Without action extending these credits, we will see the gains to health care access and affordability our country has made over the years further evaporate, and too many will not be able to pick up the slack.
Rick Pollack, president and CEO, American Hospital Association: Today is an extremely disappointing and very difficult day for health care in America. Despite months of clearly demonstrating the implications that these Medicaid proposals will have on the patients and communities we serve, especially the most vulnerable populations, Congress has enacted cuts of nearly a trillion dollars to the Medicaid program. No matter how often repeated, the magnitude of these reductions — and the number of individuals who will lose health coverage –- cannot be simply dismissed as waste, fraud, and abuse. The faces of Medicaid include our children, our disabled, our seniors, our veterans, our neighbors, and friends. The real-life consequences of these reductions will negatively impact access to care for all Americans.
The AHA remains committed to working with all stakeholders to mitigate the impact of these cuts wherever possible. Our goal is to help ensure hospitals can remain open for their communities, and people can get the care they need when they need it. Our nation’s health and economic future depend on it.
