On July 4, 2025, Congress enacted the Budget Reconciliation Act of 2025, informally known as the One Big Beautiful Bill Act, a sweeping legislative package that includes more than $1 trillion in reductions in support through 2034 (publichealth.jhu.edu).
Medicaid: Work Requirements
A monthly “community engagement” requirement will start on January 1st, 2027 that mandates able-bodied Medicaid recipients aged 19–64 to log at least 80 hours of work, volunteering, or schooling to maintain coverage. Recipients will have to verify this monthly, which introduces significant reporting burdens.
Medicare: Reduced Support & Loss of Coverage
The new law brings major Medicare changes:
- Reduces premium support for the 40% of beneficiaries who rely on the Low-Income Subsidy (LIS) program, meaning they’ll pay more for prescriptions.
- Delays a planned rule that would have streamlined Medicare Savings Program enrollment until 2034, impacting access to cost-sharing help for low-income individuals.
- Restricts Medicare eligibility to U.S. citizens, green card holders, and a few select immigrant groups. This removes coverage for many legally present immigrants, including refugees, asylees, those with temporary protected status, and some permanent residents.
ACA Marketplace: Subsidy Expiration & Enrollment Constraints
- The enhanced ACA premium tax credits are set to expire, meaning premiums could rise significantly in 2026, potentially doubling in some areas.
- Reenrollment is no longer automatic. Applicants have to reenroll manually every year during the enrollment period.
- The enrollment period will be shortened by a month, until Dec 15th.
- Beginning Jan. 1, 2027, certain legal immigrants, such as refugees, asylees, and those with temporary protected status, will lose eligibility for ACA subsidies. DACA recipients will be barred from buying Marketplace coverage nationwide.
Projected Impact: Coverage Loss & Strain on Providers
- The Center on Budget and Policy Priorities estimates the legislation could result in up to 15 million more uninsured Americans by 2034.
- Groups serving rural communities, children, the elderly, and people with disabilities have raised concerns that reduced Medicaid reimbursement and stricter eligibility requirements may lead to rural hospital and nursing home closures, further worsening health disparities.
What to Watch Next
- Will Congress renew the COVID-era ACA subsidies before they expire at the end of 2025?
- How will states implement new Medicaid work rules, especially in expansion versus non-expansion states?
- What mechanisms will CMS use to enforce the new marketplace eligibility rule, and how effectively will improper enrollments be addressed?
Understanding these policy shifts is essential for navigating care delivery and patient access in the coming years.
Source: “The Changes Coming to the ACA, Medicaid, and Medicare,” Johns Hopkins Bloomberg School of Public Health, July 30, 2025
https://publichealth.jhu.edu/2025/the-changes-coming-to-the-aca-medicaid-and-medicare
