New legislation signed by Donald Trump is expected to slash nearly $1 trillion from Medicaid and the Affordable Care Act over the next decade. Health experts warn that this could leave more than 16 million Americans without coverage, particularly affecting immigrants, people with disabilities and rural communities.
The US healthcare landscape is facing one of its most significant policy shifts in decades following the passage of President Trump’s so-called “One Big Beautiful Bill”. While the administration insists the reforms will improve efficiency and reduce fraud, independent assessments suggest that the consequences for vulnerable populations may be severe.
The law, which includes sweeping changes to Medicaid eligibility, work requirements and funding mechanisms, has already triggered warnings from state officials, public health organisations and healthcare economists. Many argue that the real-world impact of the legislation will disproportionately affect low-income communities, people with chronic health conditions, and legally residing immigrants.
New Requirements and Funding Cuts Will Affect Eligibility and Access
According to the Congressional Budget Office (CBO), the legislation will reduce federal spending on Medicaid and the Children’s Health Insurance Program (CHIP) by over $1.02 trillion by 2034. The cuts stem primarily from tighter eligibility restrictions, mandatory work requirements of 80 hours per month for childless adults aged 19 to 64, and more frequent verification of income and residency.
Dr William H. Dow, professor of public health at the University of California, Berkeley, described the measure as “the largest regressive cut in federal health benefits ever enacted in the United States.” His remarks align with findings from the Center for American Progress, which concluded that at least 11.8 million people may lose Medicaid coverage due to the law.
Though people with disabilities are formally exempt, the bureaucratic demands required to maintain eligibility may result in many being excluded from benefits. A 2018 trial of similar work requirements in Arkansas led to 18,000 people losing coverage in just seven months, mainly due to administrative challenges rather than non-compliance.
Legal Immigrants and Rural Residents Face Rising Health Risks
The law also introduces major restrictions affecting immigrants. It redefines eligibility criteria for Affordable Care Act (ACA) subsidies, potentially excluding refugees, asylum seekers and immigrants with humanitarian protection. Legal immigrants who have contributed to Medicare could also lose access under new provisions that eliminate their eligibility.
States that provide Medicaid-like support to undocumented immigrants may be penalised financially, with California and Illinois already freezing new enrolments due to projected funding losses. The American Nurses Association has expressed concern over the impact on rural communities, where Medicaid represents a critical source of hospital funding. Around 44% of rural hospitals currently operate at a loss, and experts say up to 300 facilities could be at risk of closure.
According to a study published in JAMA Health Forum by Dr Sanjay Basu of Waymark, the legislation could lead to over 1,000 additional deaths annually, increased medical debt, and nearly 100,000 extra hospitalisations due to delayed or denied care.
