The public health provisions in the massive spending package that President Donald Trump signed into law on July 4, 2025, will reduce Medicaid spending by more than US$1 trillion over a decade and result in an estimated 11.8 million people losing health insurance coverage.

As researchers studying rural health and health policy, we anticipate that these reductions in Medicaid spending, along with changes to the Affordable Care Act, will disproportionately affect the 66 million people living in rural America – nearly 1 in 5 Americans.

People who live in rural areas are more likely to have health insurance through Medicaid and are at greater risk of losing that coverage. We expect that the changes brought about by this new law will lead to a rise in unpaid care that hospitals will have to provide. As a result, small, local hospitals will have to make tough decisions that include changing or eliminating services, laying off staff and delaying the purchase of new equipment. Many rural hospitals will have to reduce their services or possibly close their doors altogether.

Hits to rural health

The budget legislation’s biggest effect on rural America comes from changes to the Medicaid program, which represent the largest federal rollback of health insurance coverage in the U.S. to date.

First, the legislation changes how states can finance their share of the Medicaid program by restricting where funds states use to support their Medicaid programs can come from. This bill limits how states can tax and charge fees to hospitals, managed care organizations and other health care providers, and how they can use such taxes and fees in the future to pay higher rates to providers under Medicaid. These limitations will reduce payments to rural hospitals that depend upon Medicaid to keep their doors open.

Second, by 2027, states must institute work requirements that demand most Medicaid enrollees work 80 hours per month or be in school at least half time. Arkansas’ brief experiment with work requirements in 2018 demonstrates that rather than boost employment, the policy increases bureaucracy, hindering access to health care benefits for eligible people. States will also now be required to verify Medicaid eligibility every six months versus annually. That change also increases the risk people will lose coverage due to extra red tape.

The Congressional Budget Office estimates that work requirements instituted through this legislative package will result in nearly 5 million people losing Medicaid coverage. This will decrease the number of paying patients at rural hospitals and increase the unpaid care hospitals must provide, further damaging their ability to stay open.

Additionally, the bill changes how people qualify for the premium tax credits within the Affordable Care Act Marketplace. The Congressional Budget Office estimates that this change, along with other changes to the ACA such as fewer and shorter enrollment periods and additional requirements for documenting income, will reduce the number of people insured through the ACA Marketplace by about 3 million by 2034. Premium tax credits were expanded during the COVID-19 pandemic, helping millions of Americans obtain coverage who previously struggled to do so. This bill lets these expanded tax credits expire, which with may result in an additional 4.2 million people becoming uninsured.

An insufficient stop-gap

Senators from both sides of the aisle have voiced concerns about the legislative package’s potential effects on the financial stability of rural hospitals and frontier hospitals, which are facilities located in remote areas with fewer than six people per square mile. As a result, the Senate voted to set aside $50 billion over the next five years for a newly created Rural Health Transformation Program.

These funds are to be allocated in two ways. Half will be directly distributed equally to states that submit an application that includes a rural health transformation plan detailing how rural hospitals will improve the delivery and quality of health care. The remainder will be distributed to states in varying amounts through a process that is currently unknown.

While additional funding to support rural health facilities is welcome, how it is distributed and how much is available will be critical. Estimates suggest that rural areas will see a reduction of $155 billion in federal spending over 10 years, with much of that concentrated in 12 states that expanded Medicaid under the Affordable Care Act and have large proportions of rural residents.

That means $50 billion is not enough to offset cuts to Medicaid and other programs that will reduce funds flowing to rural health facilities.

Accelerating hospital closures

Rural and frontier hospitals have long faced hardship because of their aging infrastructure, older and sicker patient populations, geographic isolation and greater financial and regulatory burdens. Since 2010, 153 rural hospitals have closed their doors permanently or ceased providing inpatient services. This trend is particularly acute in states that have chosen not to expand Medicaid via the Affordable Care Act, many of which have larger percentages of their residents living in rural areas.

According to an analysis by University of North Carolina researchers, as of June 2025 338 hospitals are at risk of reducing vital services, such as skilled nursing facilities; converting to an alternative type of health care facility, such as a rural emergency hospital; or closing altogether.

Maternity care is especially at risk.

Currently more than half of rural hospitals no longer deliver babies. Rural facilities serve fewer patients than those in more densely populated areas. They also have high fixed costs, and because they serve a high percentage of Medicaid patients, they rely on payments from Medicaid, which tends to pay lower rates than commercial insurance. Because of these pressures, these units will continue to close, forcing women to travel farther to give birth, to deliver before going full term and to deliver outside of traditional hospital settings.

And because hospitals in rural areas serve relatively small populations, they lack negotiating power to obtain fair and adequate payment from private health insurers and affordable equipment and supplies from medical companies. Recruiting and retaining needed physicians and other health care workers is expensive, and acquiring capital to renovate, expand or build new facilities is increasingly out of reach.

Finally, given that rural residents are more likely to have Medicaid than their urban counterparts, the legislation’s cuts to Medicaid will disproportionately reduce the rate at which rural providers and health facilities are paid by Medicaid for services they offer. With many rural hospitals already teetering on closure, this will place already financially fragile hospitals on an accelerated path toward demise.

Far-reaching effects

Rural hospitals are not just sources of local health care. They are also vital economic engines.

Hospital closures result in the loss of local access to health care, causing residents to choose between traveling longer distances to see a doctor or forgoing the services they need.

But hospitals in these regions are also major employers that often pay some of the highest wages in their communities. Their closure can drive a decline in the local tax base, limiting funding available for services such as roads and public schools and making it more difficult to attract and retain businesses that small towns depend on. Declines in rural health care undermine local economies.

Furthermore, the country as a whole relies on rural America for the production of food, fuel and other natural resources. In our view, further weakening rural hospitals may affect not just local economies but the health of the whole U.S. economy.

What’s in the new budget bill signed into law by Trump

Washington — The House passed a massive spending and tax bill that includes signature policies of President Trump’s second-term agenda Thursday, sending the so-called “big, beautiful bill” to the president’s desk ahead of a July 4 deadline. Mr. Trump signed the bill into law on Friday afternoon.

The House approved the bill in a 218 to 214 vote Thursday, after the Senate narrowly approved the bill Tuesday in a 51-50 vote that required Vice President JD Vance to break a tie.

At the center the “big, beautiful bill” is an extension of Mr. Trump’s 2017 Tax Cuts and Jobs Act, which was slated to sunset at the end of the year. The legislation would make most of the tax cuts permanent, while increasing spending for border security, defense and energy production.

The bill is partially paid for by significant cuts to health care and nutrition programs, like Medicaid and the Supplemental Nutrition Assistance Program, or SNAP. The Congressional Budget Office estimates the bill would add $3.4 trillion to federal deficits over the next 10 years and leave millions without health insurance. Republicans and the White House dispute those forecasts.

Senate Republicans used a process known as budget reconciliation to pass the bill, which limits the types of policies that can be included in a simple majority vote. A handful of provisions that initially appeared in the bill were ultimately removed, including one that would have ordered the sale of public lands and another that would have paused state regulations on artificial intelligence.

The House passed its own initial version of the legislation last month, with some key differences to the final Senate-crafted version. The lower chamber approved the Senate’s changes Thursday, sending the measure to the president’s desk.

Here’s what is in the 887-page bill:

Medicaid restrictions

The legislation includes restrictions on Medicaid, which provides government-sponsored health care for low-income and disabled Americans. The bill imposes work requirements for some able-bodied adults and more frequent eligibility checks. The Congressional Budget Office estimates that the bill would result in 11.8 million Americans losing health coverage under Medicaid over the next decade.

The Senate parliamentarian determined that a measure cutting federal funds to states that use Medicaid infrastructure to provide health care coverage to undocumented immigrants, along with banning Medicaid from covering gender transition services, wasn’t in compliance with Senate reconciliation rules. The parliamentarian also weighed in on what’s known as the provider tax, which states use to help fund their portion of Medicaid costs, in a blow to the Senate GOP’s initial plan.

Senate Republicans proposed steeper cuts to Medicaid funding, in part by incrementally lowering provider taxes from 6% to 3.5% by 2032. The timeline is delayed by one year from the Senate GOP’s initial proposal, after the issue became one of the bill’s sticking points in recent weeks. It’s a departure from the initial House-passed bill, which sought to lower federal costs by freezing states’ provider taxes at current rates and prohibiting them from establishing new provider taxes.

The bill also includes a rural hospital stabilization fund after some GOP senators expressed concern over how rural hospitals could be impacted by the Medicaid restrictions, allocating $50 billion for rural hospitals over the same period that the provider taxes would be lowered.

Homeland security and immigration

The legislation includes more than $46.5 billion for border wall construction and related expenses, $45 billion to expand detention capacity for immigrants in custody and about $30 billion in funding for hiring, training and other resources for U.S. Immigration and Customs Enforcement.

It also includes a minimum $100 fee for those seeking asylum, down from the $1,000 fee outlined in the initial House bill. The Senate parliamentarian ruled out the $1,000 fee for anyone applying for asylum.

Increasing the state and local tax deduction, or SALT

The package also includes an increase to the cap on the state and local tax deduction, raising it from $10,000 to $40,000. After five years, it would return to $10,000, a departure from the initial House-passed bill.

The issue was a major sticking point in the House, where blue-state Republicans threatened to withhold their support without the increase to the deduction. But with no Republicans hailing from blue states in the Senate, the upper chamber has been contending with its own dynamics.

Before the rule, taxpayers could deduct all their state and local taxes from their federal taxes, which some policymakers have said mainly benefits wealthy homeowners in states with high taxes, such as New York and California. But advocates for increasing the caps argue that the $10,000 cap is increasingly impacting middle-class homeowners who live in regions where property taxes are rising.

Green energy policies

The final bill passed by the Senate would largely terminate numerous tax incentives from the 2022 Inflation Reduction Act for clean energy, electric vehicles and energy efficiency programs that benefited consumers.

It would end tax credits for new and used electric vehicles, installation of home EV charging equipment and insulation or energy efficient heating and cooling systems.

The bill also ends the Greenhouse Gas Reduction Fund, which gives funding to nonprofit organizations providing financing for projects that reduce pollution and greenhouse gas emissions in communities. Existing contracts and grants under the program are not affected.

Restrictions on food stamps

The bill still shifts the costs of SNAP, or food stamps, to some states. The program is currently fully funded by the federal government.

The federal government would continue to fully fund the benefits for states that have an error payment rate below 6%, beginning in 2028. States with error rates above 6% would be on the hook for 5% to 15% of the costs. States are also given some flexibility in calculating their share.

The package also aligns with the initial House version on age requirements for able-bodied adults to qualify for SNAP benefits. Currently, in order to qualify, able-bodied adults between 18 and 54 must meet work requirements. Both the Senate and House bills would update the age requirement to 18 and 64, with some exemptions for parents.

Alaska and Hawaii could receive waivers for the work requirements if it’s determined that they’re making a “good faith effort” to comply.

Addressing the debt limit

The legislation would raise the debt ceiling by $5 trillion, going beyond the $4 trillion outlined in the initial House-passed bill. Congress faces a deadline to address the debt limit later this summer.

Treasury Secretary Scott Bessent has urged Congress to address the debt limit by mid-July, saying that the U.S. could be unable to pay its bills as early as August, when Congress is on recess.

By addressing the debt ceiling as part of the larger package, Republicans in Congress aimed to bypass negotiating with Democrats on the issue. Unlike most other legislation in the Senate, the budget reconciliation process that governs the package requires a simple majority, rather than the 60-vote threshold to move forward with a bill.

Child tax credit

The current $2,000 child tax credit is set to return to the pre-2017 level of $1,000 in 2026. The tax credit would permanently increase to $2,200 under the bill, $300 less than the initial House-passed hike.

Limits on overtime and tips deductions

The bill would allow individuals to deduct a certain amount of tip wages and overtime from their taxes. The provisions would expire in 2028.

The “no tax on tips” provision in the spending bill would create a new deduction for tipped workers, eliminating what they owe in federal income tax. Tipped workers would still have to pay state and local income tax and payroll taxes.

The Senate version varies from the initial House-passed provisions on a few key points, including how much a worker could claim in deductions. The Senate proposal limits that deduction to $25,000, while the early House version was uncapped.

Under the initial House measure, meanwhile, only people with annual income of $160,000 or less would have qualified for the tipping tax break, while the Senate version phases out benefits for individuals whose income exceeds $150,000 or couples whose income exceeds $300,000.

Changes to standard deduction

The bill seeks to permanently expand the basic standard deduction, which was nearly doubled in 2017. The increases will expire at the end of the year.

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Billions in Medicaid cuts passed by Republicans as part of President Trump’s “One Big Beautiful Bill” will have widespread negative implications on people across the United States, multiple experts told Newsweek.

Why It Matters

Trump’s touted tax overhaul and spending cuts package, which passed Thursday on a 218-214 vote in the House after months of haggling in both chambers of Congress, has provoked broader concerns about health care access and funding—notably to vulnerable populations who rely on Medicaid and the social safety net.

The CBO estimates the roughly $1 trillion in Medicaid cuts over the next decade will result in 12 million people losing coverage by 2034. Trump had repeatedly promised not to cut Medicaid benefits, including by the White House’s own admission as recently as March. The cuts are deeply unpopular, according to polls, and present a political challenge for Republicans ahead of next year’s midterm elections.

What Is the Big, Beautiful Bill?

The One Big Beautiful Bill Act is a sweeping reconciliation package that advances Trump’s domestic policy agenda. It includes major tax reforms, spending cuts, and regulatory changes across multiple sectors. The bill passed the House and Senate along party lines and is positioned as a cornerstone of Trump’s second-term legislative goals.

Numerous experts predict that Medicaid cuts and new requirements in President Trump’s “One Big Beautiful Bill” will have widespread implications on Americans and state, federal funding mechanisms. Numerous experts predict that Medicaid cuts and new requirements in President Trump’s “One Big Beautiful Bill” will have widespread implications on Americans and state, federal funding mechanisms. Photo-illustration by Newsweek/Getty/Canva

The 1,200‑page package will:

Permanently extend the 2017 Trump tax cuts, while exempting overtime pay, tips and some Social Security income from taxation.

Impose 80‑hour‑per‑month work requirements on many adults receiving Medicaid and apply existing SNAP work rules to additional beneficiaries.

Repeal most clean‑energy tax credits created under President Biden.

Authorize a $40 billion border security surge and fund a nationwide deportation initiative.

Raise the federal debt ceiling by $5 trillion, with the Congressional Budget Office estimating that it could add $3.4 trillion to the deficit over the next 10 years.

When Did the Big, Beautiful Bill Pass the Senate?

The bill narrowly passed the Senate on Tuesday after an overnight session.

The 50-50 vote generally along partisan lines was tipped in Republicans’ favor by Vice President JD Vance, who cast the decisive tiebreaker vote.

Has the Big, Beautiful Bill Been Signed?

President Trump signed his package of tax breaks and spending cuts into law Friday during a White House ceremony.

How the Big, Beautiful Bill Will Impact Medicaid Beneficiaries

The bill includes changes to eligibility for Medicaid, including mandating that Medicaid recipients must carry out some kind of work for at least 80 hours a month, which has prompted many health care experts and lawmakers to warn that it will only push millions off the program.

Other concerns include diminished care in rural communities and increased out-of-pocket costs for doctors’ visits.

To accommodate the bill’s signature tax cuts, which mostly benefit the wealthy, the cuts have to come from somewhere, according to Miranda Yaver, assistant professor of health policy and management at the University of Pittsburgh.

Consistent with prior Republican approaches, the cuts are coming from America’s safety net programs, she said.

“One in five Americans relies on Medicaid for their health coverage, and one in seven Americans relies on SNAP for their food security, so cutting these critical programs will be devastating,” Yaver said.

Roughly 92 percent of Medicaid beneficiaries are already working or would be exempt, according to KFF.

But what threatens their coverage is not noncompliance with work hours; rather, the administrative burdens of documenting their work or exemption, according to Yaver.

“For that reason, the requirement can be better characterized not as a work requirement, but rather as a paperwork requirement. … Some have characterized Medicaid paperwork requirements as a solution in search of a problem, because contrary to some characterizations of people playing video games in basements, most people on Medicaid are working or would be exempt,” she said.

A Medicaid accepted here sign in Kokomo, Indiana, in September 2019. A Medicaid accepted here sign in Kokomo, Indiana, in September 2019. GETTY

“I don’t think it’s a solution in search of a problem so much as it is a solution to a different problem: low-income Americans being provided health insurance.”

Jake Haselswerdt, associate professor at the Truman School of Government & Public Affairs at the University of Missouri, agreed that the paperwork aspect is likely going to be an issue.

“We’re going to have to see, what are the regulations look like? How do states implement this?” Haselswerdt told Newsweek. “But I’m not optimistic, especially coming from a Missouri standpoint.

“We have maybe the worst Medicaid agency in the country. The call center wait times at times have been the worst in the country.”

Chris Howard, professor of government and public policy at William & Mary, told Newsweek that cuts to Medicaid and to the Affordable Care Act [ACA] will have “profound effects” at the state level.

Millions of people across the country will lose health insurance, he said, including an estimated 300,000 in his state of Virginia.

“Basically, Republicans are trying to undermine big parts of the [Affordable Care Act, or Obamacare] without having to replace them,” Howard said. “They learned that ‘repeal and replace’ did not work in Trump’s first term, so now they just want to repeal.”

Large rural populations in some of the hardest hit states, like Virginia and Kentucky which have expanded Medicaid under the ACA, will receive reduced federal funding for individuals who rely on Medicaid.

“States can’t run budget deficits, and they are highly unlikely to replace all the lost funds,” Howard said. “More people will lose coverage. In the health care system, every dollar of benefit to someone is also a dollar of income to someone else.

“Hospitals and nursing homes, especially in rural areas, depend heavily on Medicaid dollars. Many of them will have to lay off workers or close down. If hospitals have to provide more uncompensated care to the uninsured, there will be pressure on private insurance to raise rates.”

Rural hospital closures not only increase driving distances for medical care, Yaver said, but they can also deter businesses from operating in communities with economic downturn.

She called the rural hospital fund in the bill “a drop in the bucket relative to the devastation headed their way.”

Haselswerdt said the ramifications on Americans’ health and wellbeing will also take a hit. The rural hospital fund, which was previously around $25 billion before being bumped up to $50 billion, won’t be enough across all 50 states, he said.

“Nothing’s permanent because policy can change, but we think of them as permanent cuts—this kind of short-term, financial Band-Aid,” Haselswerdt said. “I don’t really think makes that much of a difference. [When] people lose coverage that means these hospitals are delivering more freer charity care that never gets paid for.

“That was something that was demonstrated with the ACA. When coverage expanded under the ACA, it helped hospitals; they had less uncompensated care to deal with. So, if you change policy in such a way that more people are showing up at hospitals without health coverage, it’s not going to be good for those hospitals.”

President Donald Trump, from left, speaks as Health and Human Services Secretary Robert F. Kennedy Jr. and Dr. Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, listen during an event in the… President Donald Trump, from left, speaks as Health and Human Services Secretary Robert F. Kennedy Jr. and Dr. Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, listen during an event in the Roosevelt Room at the White House, Monday, May 12, 2025, in Washington. More Associated Press

What the White House Has Said About Impact on Medicaid

A “Myth vs. Fact” sheet released by the White House on June 29 responds to numerous critiques of the One Big Beautiful Bill, including on Medicaid.

The White House called it a “myth” that the legislation “kicks American families off Medicaid.”

“As the President has said numerous times, there will be no cuts to Medicaid,” the statement reads. “The One Big Beautiful Bill protects and strengthens Medicaid for those who rely on it—pregnant women, children, seniors, people with disabilities, and low-income families—while eliminating waste, fraud, and abuse.

“The One Big Beautiful Bill removes illegal aliens, enforces work requirements, and protects Medicaid for the truly vulnerable.”

Update 7/5/25 10:38 a.m. ET: This story has been updated to reflect the increase in rural hospital funding.

Changes to the Affordable Care Act Marketplace will result in premium costs increasing by an average of almost $1,300 annually.

United States President Donald Trump’s signature piece of budget legislation, the “One Big Beautiful Bill”, will likely raise healthcare costs, experts have said. While the Medicaid cuts will directly impact those who depend on the programme, the consequences will extend to others as well.

The 869-page bill, which includes roughly $1 trillion in cuts to Medicaid over the next decade, passed in the House along party lines, with only two Republicans – Representatives Thomas Massie of Kentucky and Brian Fitzpatrick of Pennsylvania – breaking ranks. It will be signed into law by Trump on Friday.

In addition to patients, Medicaid funds also help financially strapped hospitals and other healthcare facilities, and the cuts could lead to their closures.

Apart from this, almost 12 million people could lose health insurance by 2034 due to reductions to both Medicaid and the Affordable Care Act marketplace, according to a Congressional Budget Office analysis.

Experts warn the new law will drive up costs elsewhere in the system. Patients may face higher out-of-pocket expenses, while hospitals could be forced to lower the quality of care, raise prices, or close entirely due to the financial strain.

“There is the mistaken belief that cuts in Medicaid will only affect those on Medicaid. Many hospitals, clinics, and healthcare organisations depend on Medicaid funding for their operations. Therefore, cuts in Medicaid can adversely affect the types and quality of services they provide,” Bruce Y Lee, professor of health policy at the CUNY Graduate School of Public Health and Health Policy, told Al Jazeera.

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“In fact, a number of healthcare organisations depend so heavily on Medicaid funding that they could go out of business with significant cuts.”

The cuts would hit rural hospitals hard, according to an analysis from the National Rural Hospital Association (NRHA). About 20 percent of the US population lives in rural areas, where Medicaid covers one in four adults, a higher share than in urban areas, and plays a large part in financing healthcare services.

The cuts are expected to result in a 20 percent reduction in funding for rural hospitals in half of all states.

That will hurt patients like Martha Previte and her partner Jim Earl, who live in rural Maine. Both have type 1 diabetes and rely on regular hospital visits for a range of procedures, including blood tests and kidney treatment.

“I fear that these cuts are going to close hospitals that we rely on to get care, and we’re not going to have anywhere to go,” Previte told Al Jazeera.

This bill could result in as many as 338 hospitals closing around the US. There are already nearly 800 hospitals that are facing financial hardship.

“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,” the American Hospital Association said in a statement condemning the bill’s passage and calling it “an extremely disappointing and very difficult day for health care in America”.

Those that stay open could result in cuts to essential care like chemotherapy and behavioural health services.

The bill does include $50bn for rural hospitals to offset the additional financial strain they will face. But because of cuts to Medicaid, that funding will not make enough of a dent to keep healthcare costs from rising and healthcare facilities from shuttering.

Analysis from the Kaiser Family Foundation found that Medicaid cuts would still lead to a drop of $155bn in federal Medicaid spending on rural hospitals over the next 10 years.

“While the President promised to lower costs for Americans, this bill is set to spike premiums and other healthcare costs,” Elizabeth Pancotti, managing director of policy and advocacy at the Groundwork Collaborative, told Al Jazeera.

Rural hospitals in the state of Missouri will be the hardest hit and are expected to lose an average of 29 percent of Medicaid funding. While Missouri’s Senator Josh Hawley, in a May op-ed in the New York Times, said cuts to Medicaid would be “politically suicidal”, he and his fellow Missouri senator, Republican Eric Schmitt, voted in support of the bill before it moved to the House of Representatives on Tuesday.

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The cuts are also expected to affect nursing homes disproportionately in urban areas, according to an analysis from Brown University School of Public Health, which forecast that 579 nursing homes could shutter. Those at highest risk have a Medicaid payer share greater than 85 percent. It was found that the Medicaid cuts overwhelmingly affected nursing homes in California, Georgia, Illinois and Texas.

Looming Medicare changes

Medicaid is not the only healthcare programme seeing cuts. While Medicaid is intended for those who are low-income, Medicare covers healthcare for those 65 and older, as well as some others who have disabilities. Some patients, like Previte, receive both.

“Medicare is my primary insurer, and Medicaid picks up what Medicare does not cover. I am a type 1 insulin-dependent diabetic of 41 years with serious complications. Medicare covered my recent hospitalisation and upcoming outpatient procedures,” Previte told Al Jazeera.

The Republican bill could also indirectly lead to cuts in Medicare services because of the statutory Pay‑As‑You‑Go Act of 2010. Under this, the White House’s Office of Management and Budget is required to keep a “scorecard” to track net increases to the deficit, with a goal to “eliminate the overage”.

Because of that, the programme may not get all of the money allocated to it, a potential $490bn loss in access to funds over the next decade, according to the Congressional Budget Office, affecting coverage for people who rely on Medicare.

“The whole thing [the tax bill] is a stark abandonment of human social responsibility,” Previte’s partner Earl said.

Affordable Care Act changes

The upcoming law also makes significant changes to the Affordable Care Act, otherwise known as Obamacare. It shortens the annual enrollment period for healthcare coverage by about a month and drives up premium costs for those who need it.

According to analysis from the Kaiser Family Foundation, insurance premium prices could increase on average by $1,296 a year.

Those who get their healthcare coverage through the exchange will also need to annually update their personal information, which includes income and immigration status, rather than being enrolled automatically.

The changes will cause a strain on the small business economy. Last year, as many as 3.3 million self-employed individuals and small business owners relied on the marketplace for health insurance.

“If you’re a young business owner, already stretched thin by housing costs, child care bills, and health premiums, this bill just made your future harder,” Richard Trent, executive director of Main Street Alliance, an advocacy group for small businesses, said in a statement.

Former President Barack Obama, in a post on X, weighed in as the bill strips parts of his signature policy, a key part of his legacy.

“It will increase costs and hurt working class families for generations to come,” the former president said in a post before the bill’s passage.

“This will be another branch of a limb of a disastrous tree. I’m concerned about what this means for our future care. The thing with diabetes, like many ailments, they’re livable if they’re treated properly. You can live a long, happy, healthy life, but when you’re deprived of healthcare, maintenance-of-health care, and things like that, then a whole Pandora’s box of disasters can happen to your health,” Earl added.

When Hurricane Helene drowned western North Carolina in muck and floodwater last year, it caught folks off-guard.

Now, local leaders in places like Asheville expect the Republican-led reconciliation bill – called the “big, beautiful bill” by Donald Trump – to bear down on rural America. And they wonder whether people are missing the warning signs.

“It’s going to have to hit them first,” said Laurie Stradley, CEO of Impact Health in Asheville, a Medicaid-funded non-profit providing social services to some people still digging out from the flood.

Medicaid is the single largest health insurance program in the US. The public program covers 71 million low-income, disabled and elderly US residents. It pays for half of all US births and the care of six in 10 nursing home residents.

When Trump’s sprawling tax-and-spending bill passed on Thursday, it heralded more than $1tn in federal cuts to Medicaid, which experts worry will push Republican-led states to abandon parts of the program and leave people without access to timely healthcare.

“This is an extraordinarily regressive bill,” said Joan Akler, executive director and co-founder of Georgetown University’s Center for Children and Families. “This is the largest rollback of healthcare coverage that we’ve ever seen and all in service of an agenda to drive tax cuts that will disproportionately benefit wealthy people and corporations.”

Medicaid “expansion” is a key provision of Obamacare, formally called the Affordable Care Act of 2010. The expansion provides largely no-cost health insurance to people earning up to 138% of the federal poverty level, or $36,777 for a family of three. Although Obamacare has been the law for more than a decade, Medicaid expansion proved politically divisive in Republican states, and many only recently decided to accept enormous federal subsidies to cover their residents.

North Carolina will lose $32bn in the next decade

The Medicaid cuts in the bill could have particularly acute consequences in North Carolina, a politically competitive state, where experts said the bill could trigger a “kill switch” to end Medicaid expansion.

“If the state spends any state dollars to implement the expansion population or expansion coverage, it triggers an automatic ending to Medicaid expansion,” said Kody Kinsley, North Carolina’s former secretary of health and an architect of the state’s Medicaid expansion.

North Carolina is set to lose $32bn in federal funding in the next decade, according to an analysis by the office of the Republican senator Thom Tillis, who represents the state. He’s one of just three Senate Republicans who voted against the bill on Tuesday.

North Carolina’s expansion only went into effect in December 2023, and in less than 19 months it enrolled more than 650,000 people – all of whom will lose coverage if the program ends.

Those North Carolinians are only some of the 17 million people expected to lose health insurance by 2034 across the country, according to estimates from the non-partisan Congressional Budget Office. Nearly 12 million people will lose insurance because of attacks on Medicaid.

“Ultimately, Medicaid being cut is going to kill people,” said Molly Zenkler, a nurse at Mission hospital in Asheville. “I deal with people getting their feet literally amputated because they don’t have access to diabetic care. This is just going to get increasingly worse.”

The reconciliation bill cuts state funding through a number of provisions. On healthcare specifically, the bill attacks complex financial maneuvers states use to draw down federal funds. It also requires states to spend enormous sums – perhaps tens of millions of dollars per state – implementing work requirements, effectively adding layers of expensive red tape.

Congressional Republicans in favor of the bill argue it targets “waste, fraud and abuse”. However, it is already well-known that most Medicaid beneficiaries who can work do, and that Medicaid is one of the most cost-efficient health programs in the US, according to the American Hospital Association.

North Carolina is one of a dozen conservative states that wrote a “trigger” law into Medicaid expansion. Not all function like North Carolina’s – the laws are, in the words of an expert with Georgetown University’s McCourt School of Public Policy, a “lesson in federalism” – but they nevertheless underscore the difficult choices state legislators will face because of congressional Republicans’ cuts.

One such program that could be on the chopping block is a pilot with Impact Health, which uses Medicaid expansion funds for social needs that affect health – an effort to reduce long-term costs. Stradley gave the example of a Medicaid-covered child with severe asthma who hit the local emergency room three times a week for breathing treatments.

Impact’s program used Medicaid funds to replace moldy rugs with laminate flooring in the child’s home, and to buy a vacuum with a Hepa filter. The cost to Impact Health was about $5,000, “but now this child is going to the emergency room a couple times a year instead of a couple times a month. And so, every month we’re saving about $4,500.”

The program’s knock-on effects boost the local economy: the work to replace the rug was done by a local carpenter, and the child’s mother isn’t calling out from work, increasing her job stability.

“One of the ways that we talk about this program is that it’s a hand up rather than a handout,” she said. “Almost half of the folks that are recipients in our program are children … Then you look at the adults. Most of them are working multiple jobs, and those jobs don’t come with benefits, because they’re working two or three part-time jobs in order to make ends meet.”

The enormity of Medicaid means large cuts to the program imperil not only patients, but the institutions that serve them – especially rural hospitals and clinics hanging on “by a thread”, according to Kinsley.

One of US residents’ few rights to healthcare is in emergency departments, where hospitals are required to stabilize patients regardless of ability to pay. That makes emergency departments the go-to source for healthcare for the uninsured.

An analysis released by the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill earlier this year showed that 338 rural hospitals around the country were at risk of imminent closure with the cuts to Medicaid contained in the bill.

‘Hospitals will be forced to restrict services, or close’

Rural states such as Kentucky are expected to be disproportionately hard-hit as well. Thirty-five of the rural hospitals at risk of closure – about 10% – are in Kentucky, even though Kentucky’s 4.5 million residents comprise about 1.3% of the US’s population. About a third of Kentucky residents are on Medicaid, according to figures from Kentucky’s cabinet for health and family services. The program benefits about 478,900 adults.

The situation is similarly dire in Arizona, another battleground state, which also has a trigger law on the books. Although the reconciliation bill may not “trigger” a rollback of Medicaid expansion, it does undermine a key financing mechanism for the state’s program called a “provider tax”.

“We estimate Arizona’s healthcare system would lose over $6bn over the next seven years,” said Holly Ward, a spokesperson for the Arizona Hospital and Healthcare Association, in a statement.

“In other words, more than 55% of Arizona hospitals would be operating in the red,” she said. “Hospitals will be, at best, forced to restrict services such as obstetrics, behavioral healthcare and other complex services, and at worst, will close their doors altogether.”

Another issue is the potential for Republicans’ cuts to drive up the cost of healthcare for Americans who are privately insured, including through employers. As hospitals fight to survive, they will try to extract as much money as possible from other sources of funding – namely, commercial insurance.

In addition, rural healthcare providers worry the water will be muddied by the sheer complexity of US healthcare. Private companies have a hand in managing – and therefore branding – state Medicaid programs.

“A lot of our rural voters may not even realize that what they have is Medicaid, because there are so many names for it,” said Stradley. However, the precarious situation is already worrying people whose lives have been stabilized because of Medicaid.

Amanda Moynihan is a single mother of three children – ages nine, 12 and 16 – living in Kuna, Idaho. Medicaid expansion has helped her become a “functioning human in society”, she said. Routine medical care for herself and her children, along with other assistance programs, has meant the difference between grinding poverty and a shot at the middle class.

Idaho, one of the most politically conservative states in the union, expanded Medicaid in 2018 with an overwhelming ballot-referendum vote of 61-39. Even if Idaho’s “trigger law” does not go into effect, the state could face similar fiscal challenges to Arizona.

“Back two years ago, before I started school, I was just in fight-or-flight, just trying to pay the bills there. I didn’t ever see a future of what I could do. And then I just started with one class,” she said.

Moynihan has completed an associate degree in psychology and is starting the social work bachelor’s degree program at Boise State University in the fall. For now, she’s working part time with the Idaho Commission for the Blind and Visually Impaired and planning to pick up work at a gas station because it has a college scholarship benefit.

But without stability to pursue higher education, her future “would be making the minimum wage, which is about $15 an hour, barely paying rent in a low-income household”.