Trump’s Healthcare Bill Could Strip Coverage for Millions

The proposed health care legislation championed by President Donald Trump, referred to as the “big, beautiful bill,” aims to introduce significant revisions to the U.S. health care system. If passed, it is projected to leave millions of vulnerable Americans without health insurance, jeopardizing the stability of hospitals and care centers that serve these populations.

On Tuesday, the Senate narrowly approved the contentious funding bill with a 51-50 vote following an extensive session dedicated to amendments. However, the bill still faces a critical hurdle in the House of Representatives, where the Republican majority is slim and several members have already voiced concerns regarding specific aspects of the legislation.

According to new estimates from the nonpartisan Congressional Budget Office (CBO), amended aspects of the legislation could slash approximately $1.1 trillion from health care spending over the next decade. A significant portion of these reductions—over $1 trillion—would impact Medicaid, the federal-state program that provides health coverage for low-income individuals and those with disabilities. These spending cuts not only threaten coverage but could also lead to the closure of numerous rural hospitals that depend heavily on federal financing.

The CBO further forecasts that the bill, in its current form, will cause an estimated 11.8 million Americans to lose their health insurance by 2034, primarily through the loss of Medicaid coverage.

In a broader context, Trump’s legislation, coupled with other proposed policy shifts, could potentially result in approximately 17 million more people being uninsured, according to Robin Rudowitz, director of KFF’s program on Medicaid and the uninsured. Additional policy changes, including stricter regulations limiting access to Affordable Care Act (ACA) Marketplace coverage and the expiration of enhanced tax credits under the ACA, could contribute to this increase.

“If fully enacted, this legislation would signify the largest rollback of health insurance coverage seen as a result of federal policy adjustments,” stated Cynthia Cox, KFF’s director of ACA programs, in a recent analysis.

Presently, there are about 72 million individuals enrolled in Medicaid, representing roughly one-fifth of the U.S. population. This program is crucial, as it serves as the primary payer for a significant percentage of nursing home residents and finances approximately 40% of all births in the country.

The Trump administration and its supporters contend that the proposed cuts aim to curb waste, fraud, and abuse within the health care system. In contrast, Democrats argue that these reductions betray Trump’s previous commitments to maintain funding for Medicaid. This issue has sparked significant division between the parties, with several House Republicans expressing unease over the degree of the proposed cuts.

“While I understand the desire to eliminate fraud, a broad approach will not effectively address the issue,” remarked Jennifer Mensik Kennedy, president of the American Nurses Association, during an interview.

She pointed out that the cuts could threaten the viability of hospitals and health centers in rural areas, ultimately resulting in job losses for healthcare professionals, including nurses.

The budget cuts included in the bill originate from several provisions, but the majority of Medicare savings are expected to result from two specific changes.

One significant change would introduce a stringent national work requirement for certain Medicaid beneficiaries aged 19 to 64. Under this provision, childless adults without disabilities and parents of children over the age of 14 would need to work, volunteer, or attend school for at least 80 hours each month to remain eligible for insurance coverage, barring specific exemptions.

Current legislation prohibits using work mandates or reporting rules to determine Medicaid eligibility, according to KFF.

The work requirement is slated to take effect in 2026 and is expected to save around $325 billion over a decade, based on CBO projections. An analysis released last week by the UC Berkeley Labor Center indicated that the work requirement could lead to significant insurance losses, particularly affecting older adults who often face barriers to employment, such as health challenges, age discrimination, and caregiving responsibilities.

“Older adults are especially susceptible to losing coverage under Medicaid work requirements due to these factors,” the analysis highlighted.

Individuals in rural areas, including seasonal workers, may also encounter difficulties finding steady employment throughout the year, Mensik Kennedy noted.

AARP, an organization dedicated to advocating for Americans aged 50 and older, recently communicated its opposition to another aspect of the bill that could deny premium tax credits for those unable to meet Medicaid work requirements when purchasing coverage through ACA Marketplaces.

This situation could create a nearly insurmountable barrier for individuals in their 50s and early 60s—particularly those approaching retirement or working part-time—by leaving them without any affordable health care options, the group stated.

Another primary source of savings for Medicaid is anticipated to stem from a provision that would limit and gradually reduce the tax that states are permitted to levy on hospitals, health insurers, and other medical service providers. These provider taxes are critical for financing state Medicaid programs, as the federal government matches a portion of state expenditures.

Some Trump administration members and conservative lawmakers argue that these provider taxes serve as a loophole, allowing states to receive a disproportionately high amount of federal funding relative to their contributions.

The CBO report estimates that the changes concerning provider taxes and state-directed payments could reduce expenses by a total of $375 billion.

However, concerns have been raised by some Republican senators and health experts, warning that capping provider taxes could jeopardize a vital funding source for rural hospitals, potentially forcing many to shut down. Mensik Kennedy emphasized that rural health providers, especially critical access hospitals, rely more heavily on Medicaid funding compared to their urban counterparts.

“The fallout could include the closure of rural hospitals, which are vital to their communities and were already facing financial uncertainty. This could lead to the loss of half a million jobs,” Mensik Kennedy cautioned.

Additionally, pregnant women in remote areas may find themselves needing to travel considerable distances—up to 60 miles or more—to give birth, and emergency services could face delays in reaching patients in critical situations such as heart attacks.

Patients in rural settings already experience high rates of chronic illnesses and mortality due to limited access to care, as reported by the Centers for Disease Control and Prevention.

To address potential closures, Senate Republicans have included a $25 billion fund aimed at supporting rural hospitals amidst the Medicaid cuts. However, Mensik Kennedy criticized this fund as insufficient, calling it “a drop in the bucket” compared to the substantial losses anticipated from provider tax caps and related provisions.

Projected reductions in overall Medicaid funding for rural hospitals could exceed 20% in more than half of the states, according to a report from the National Rural Health Association.

Republican senators have also secured a benefit for pharmaceutical companies by reintroducing a provision that would exempt additional medications from Medicare drug price negotiations under the Inflation Reduction Act.

This new legislation will allow medicines intended for multiple rare diseases to be excluded from price discussions between Medicare and manufacturers. This provision, known as the ORPHAN Cures Act, had initially been omitted from earlier drafts of the bill.

The pharmaceutical industry asserts that excluding these drugs from negotiations will promote necessary investments in treatments for rare diseases. Presently, only medications that address a single rare condition are exempt from such price negotiations.

“The ORPHAN Cures Act will broaden the range of options for Americans facing rare diseases,” the Biotechnology Innovation Organization stated in a post on X last week. The organization pointed out that only 5% of rare diseases currently have an approved treatment, while the economic burden of these diseases in the U.S. exceeds $997 billion annually.

Conversely, drug pricing advocacy group Patients For Affordable Drugs Now has urged the House to remove the ORPHAN Cures Act from the proposed legislation, advocating for Medicare drug price negotiations that could deliver considerable savings to patients.

The group’s executive director, Merith Basey, criticized the decision to include the provision, indicating that it “moves us in the wrong direction and undermines efforts to reduce drug prices.” She highlighted the influence of pharmaceutical lobbyists and labeled the provision a “completely unnecessary $5 billion giveaway” to the industry, referencing CBO estimates of its cost to taxpayers over the next decade.