In addition to the changes to Social Security and the tax code, the One Big Beautiful Bill Act (OBBBA) includes a number of provisions that will reduce access to medical coverage for Americans under Medicare, Medicaid, and the Affordable Care Act (ACA).

For instance, the Act will reduce access to both Medicaid and ACA coverage through a range of new work rules, paperwork requirements, and tighter eligibility considerations, while the delayed implementation of Medicare enrollment reforms will make it harder for low income Americans to access premium subsidies to support their coverage. Changes to ACA eligibility could likewise impact individuals on employer-provided health plans who are considering retirement before age 65, reducing access to income-based subsidies to offset their out-of-pocket costs for coverage.

According to estimates, the cuts to Medicaid alone in the OBBBA will total between $800 billion and $1.2 trillion over the next 10 years¹, putting coverage for as many as 7.8 million Americans at risk.² These cuts will likely have an outsized impact on older Americans, those living in rural areas, and immigrants. That’s because 30% of Medicaid spending goes to support older recipients who are eligible for both Medicaid and Medicare (case in point: Medicaid is the primary payer of more than 60% of nursing home residents)³, rural areas with limited healthcare access will likely lose even more hospitals and other medical facilities,⁴ and more immigrants will lose access to care once states are no longer able to use federal funds to enroll undocumented immigrants in Medicaid.

Key Changes to Medicare⁵

Enrollment Streamlining Rules Have Been Suspended Until 2035

• What’s Changing: The OBBBA is delaying previous reforms that would have automatically enrolled low-income seniors into programs like Medicare Savings or Medicaid dual eligible plans. States began implementing the earlier rule in Fall 2024.
• Potential Effect: Many seniors will continue missing out on benefits they’re entitled to, like premium-free Part B or reduced drug costs, due to lack of awareness or administrative burden.

New Limits to Medicare Eligibility

• What’s Changing: Under the new rules, Medicare eligibility is now restricted only to U.S. citizens, green card holders and certain Cuban-Haitian entrants.
• Potential Effect: Whereas previously permanent residents and other legal immigrants 65 and older were eligible for premium-free Medicare Part A if they or their spouse worked in the U.S. and paid Medicare payroll taxes for at least 40 quarters, those not in the above three groups are now excluded. The OBBBA also terminates Medicare benefits in 18 months or less for all who are currently receiving benefits but is no longer eligible under these changes.

In addition, there will likely also be ripple effects for beneficiaries over 65 who are dual eligible for Medicare and Medicaid as well based on the coming changes to Medicaid.

Key Changes to Medicaid

New Mandatory Work and Community Engagement Requirements

• What’s Changing: Starting by December 31, 2026, all adults aged 19-64 who are receiving Medicaid benefits but complete and report on 80 hours of work, volunteering, or education, unless they have a disability or are otherwise exempt.
• Potential Effect: Tens of thousands of current Medicaid enrollees – especially part-time workers or caregivers – may lose their coverage if they can’t meet these new reporting or activity requirements. The complexity of the work documentation rules in the OBBBA may confuse or discourage eligible people from reapplying for benefits.

Eligibility Redeterminations are Now Required Every 6 Months

• What’s Changing: Under the OBBBA, Medicaid expansion enrollees must re-verify their eligibility twice a year, not just once, starting after December 2026.
• Potential Effect: The increased red tape associated with this new requirement could lead to eligible individuals being dropped for missing paperwork. In addition, states with outdated technology or language barrier issues among recipients may see a spike in wrongful terminations.

New Cost-Sharing Requirements for Recipients

• What’s Changing: Starting October 1, 2028, Medicaid recipients who have incomes at or above 100% of the federal poverty level will owe up to $35 per doctor visit, capped at 5% of family income.
• Potential Effect: Many low-income Americans on Medicaid may skip care due to these new costs. Chronic care (like diabetes, asthma, or mental health visits) may become unaffordable, leading to worse long-term outcomes.

Enhanced Eligibility Verification Requirements

• What’s Changing: The OBBBA sets stricter new documentation and address check requirements that will be required to maintain coverage, especially for those flagged as high-risk or frequently moving. States will need to obtain contact information by January 1, 2027 and have a system in place to prevent enrollment in two states simultaneously by October 1, 2029.
• Potential Effect: Eligible individuals who move often (e.g., if they are unhoused, or are seniors in care transitions) could lose Medicaid coverage due to minor paperwork issues or missing mail without realizing that they need to re-verify.

Provider Tax and Payment Caps

• What’s Changing: Currently states are able to finance their share of Medicaid spending through multiple sources, including state general funds, healthcare related taxes (aka provider taxes), and local government funds. Under the OBBBA no new provider taxes are allowed and any existing taxes of this type must be capped at 3.5%-6%. In addition, states must limit Medicaid payments to 100% of Medicare rates (or 110% for states that did not adopt previous Medicaid expansions).
• Potential Effect: Some providers may stop accepting Medicaid due to these reductions in payments, limiting access to beneficiaries, especially in rural or underserved areas where options are already few.

Key Changes to the Affordable Care Act

Pre-Enrollment Verification of Eligibility for Premium Tax Credit and Other Cost Savings

• What’s Changing: Beginning after December 31, 2027, new enrollees in ACA healthcare plans will need to verify their eligibility before enrollment to receive any premium tax credits or cost-sharing reductions. The requirements include the verification of income, immigration status, health coverage status, place of residence, family size, and potentially more. This provision effectively ends auto-renewals.
• Potential Effect: As with some of the new Medicaid requirements, the paperwork and complexity related to these new requirements might convince some potential ACA customers not to apply for tax credits or cost savings.

Recapture of Excess Premium Tax Credits

• What’s Changing: Currently, if an ACA customer receives excess premium tax credits because their estimated income was lower than their actual income, they must repay the excess. However, in most cases there is a cap on these repayments that’s based on household income. Under the OBBBA, all premium tax credit recipients must repay the full amount of any excess, no matter what their income is.
• Potential Effect: Again, the risk of having to make payments on excess credits could convince some not to apply for them at all.

Reduced Access to ACA Premium Subsidies for Legal Immigrants

• What’s Changing: Legal immigrants were previously eligible to enroll in ACA Marketplace coverage and receive the same premium subsidies and cost-sharing reductions that American citizens can. In addition, these immigrants could also access ACA Marketplace coverage if their income was under 100% of the federal poverty level and they did not qualify for Medicaid due to their immigration status. The OBBBA is limiting eligibility for subsidized coverage to permanent residents, such as green card holders, and eliminating eligibility for non qualifying immigrants beginning January 1, 2026.
• Potential Effect: This could limit healthcare availability for legal immigrants and increase what they have to pay for coverage in the open market.

What This All Means for the Future of Medicare, Medicaid and ACA

The changes under the OBBBA means that individuals will need to stay informed on eligibility rules, pay attention to re-qualification requirements and be aware of how their doctors networks may change over time. For lower income Medicare enrollees, understanding your eligibility for premium subsidies will be an important cost saver until the streamlined rules are implemented in 2035.

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¹ Euhus, R., Williams, E., Burns, A., Rudowitz, R. (July 1, 2025). Allocating CBO’s Estimates of Federal Medicaid Spending Reductions Across the States: Senate Reconciliation Bill. KFF. https://www.kff.org/medicaid/issue-brief/allocating-cbos-estimates-of-federal-medicaid-spending-reductions-across-the-states-senate-reconciliation-bill/

² Alker, J., Schneider, A. (June 26, 2025). One Big Beautiful Bill Act: Winners and Losers in the Medicaid Provisions. Georgetown University McCourt School of Public Policy Center for Children and Families. https://ccf.georgetown.edu/2025/06/26/one-big-beautiful-bill-act-winners-and-losers-in-the-medicaid-provisions/

³ Medicare Payment Advisory Commission, Medicaid and CHIP Payment and Access Commission. (January 2024). Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid. https://www.macpac.gov/wp-content/uploads/2024/01/Jan24_MedPAC_MACPAC_DualsDataBook-508.pdf

⁴ Saunders, H., Burns, A., Levinson, Z. (July 2, 2025). How Might Federal Medicaid Cuts in the Senate-Passed Reconciliation Bill Affect Rural Areas? KFF. https://www.kff.org/policy-watch/how-might-federal-medicaid-cuts-in-the-senate-passed-reconciliation-bill-affect-rural-areas/

⁵ KFF. (July 8, 2025). Health Provisions in the 2025 Federal Budget Reconciliation Bill. https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/