The Big Beautiful Bill, formally known as H.R. 1, is a sweeping Republican reconciliation package that would make some of the largest changes to Medicaid in the program’s history. The Congressional Budget Office estimates that the bill’s Medicaid provisions would increase the number of people without health insurance by 7.8 million by 2034 compared to current projections. The changes touch nearly every part of the program, from who qualifies to how states fund their share of costs.
Work Requirements for Medicaid Enrollees
One of the most prominent changes is a new “community engagement” requirement. This would require certain Medicaid beneficiaries to work, volunteer, attend school, or participate in job training for a set number of hours to maintain their coverage. Work requirements have been attempted before through state waivers, but the Big Beautiful Bill would establish them in federal law for the first time.
When Arkansas briefly implemented a work requirement through a waiver in 2018, more than 18,000 people lost coverage in just a few months. Most of those who lost coverage were already working or qualified for an exemption but failed to navigate the reporting process. The concern with a federal mandate is that the same pattern would repeat on a much larger scale, with administrative barriers causing eligible people to fall off the rolls.
Stricter Eligibility Checks and Verification
The bill introduces several provisions aimed at tightening who is enrolled in Medicaid. States would be required to conduct more frequent eligibility redeterminations, verify addresses to prevent people from being enrolled in multiple states simultaneously, and remove deceased individuals from enrollment rolls. A new system for catching concurrent enrollment across state lines would also be built out over time.
More frequent eligibility checks sound straightforward, but they carry real consequences. During the 2023-2024 Medicaid “unwinding” after pandemic-era continuous coverage ended, millions of people were dropped from Medicaid for procedural reasons, not because they were actually ineligible, but because they missed a piece of mail or didn’t complete paperwork on time. Requiring more frequent redeterminations increases the chances of that happening again, particularly for people with unstable housing, language barriers, or limited internet access.
Reduced Federal Funding for Expansion States
Under the Affordable Care Act, the federal government pays 90% of the cost of covering adults who gained Medicaid through the ACA expansion, which extends eligibility to nearly all adults with incomes up to 138% of the federal poverty level (about $21,597 for an individual in 2025). Forty-one states, including Washington, D.C., have adopted this expansion.
The Big Beautiful Bill would begin reducing that enhanced federal matching rate. A provision labeled “Sunsetting Increased FMAP Incentive” would phase down the extra federal dollars that incentivized states to expand. Another provision specifically starts reducing the enhanced match for expansion states over time. If the federal share drops significantly, some states may find the expansion population too expensive to maintain and could roll back coverage entirely. This is the single provision most likely to drive large coverage losses, since roughly 20 million people are covered through the Medicaid expansion nationwide.
Changes to Retroactive Eligibility
Current Medicaid rules allow coverage to be applied retroactively for up to three months before a person’s application date. This protects people who were eligible but hadn’t yet enrolled when they got sick or injured, covering hospital bills that would otherwise be catastrophic. The bill would reduce or eliminate this retroactive coverage window.
For patients, this means the timing of your application would matter much more. If you’re hospitalized and weren’t enrolled in Medicaid at the time, you could be left responsible for bills that current law would have covered. For hospitals, especially rural and safety-net facilities, this change could increase the amount of uncompensated care they absorb.
New Limits on Noncitizen Coverage
The bill changes federal financial participation and eligibility rules for noncitizens in both Medicaid and CHIP (the Children’s Health Insurance Program). Currently, lawfully present immigrants are eligible for Medicaid in many states, and federal emergency Medicaid covers life-threatening conditions regardless of immigration status. The bill would modify the federal matching rate for emergency Medicaid and tighten eligibility for noncitizens more broadly.
The practical effect would vary by state, but it could mean that some immigrants who currently have coverage would lose it, and states that chose to continue covering them would have to pick up a larger share of the tab.
Cost Sharing and Home Equity Limits
Two smaller but meaningful provisions would increase out-of-pocket costs for some enrollees and change asset rules. The cost-sharing provision would allow or require higher copays, premiums, or other charges for Medicaid beneficiaries. Even modest cost sharing in Medicaid has been shown to reduce the use of necessary care, because the population served by the program has very little disposable income.
A separate provision changes home equity rules. Medicaid currently has limits on how much home equity a person can have and still qualify for long-term care coverage. The bill would adjust these thresholds, potentially requiring some older adults or people with disabilities to spend down more of their home’s value before qualifying for nursing home or home-based care.
Provider Payment and State Financing Changes
The bill targets how states finance their share of Medicaid through provider taxes, which are fees states charge to hospitals, nursing homes, and other providers that are then used to draw down federal matching funds. Many states rely heavily on this mechanism. The bill would lower the threshold for what counts as a permissible provider tax and reduce the “hold harmless” protections that currently allow states to return tax revenue to providers.
A new provider payment rate limit would also cap what states can pay certain providers through supplemental payment programs. States currently have significant flexibility in setting Medicaid reimbursement rates, and supplemental payments help fill the gap between what Medicaid pays and what care actually costs. Restricting these payments could reduce what hospitals and other providers receive, potentially making fewer of them willing to see Medicaid patients.
The bill also imposes stricter budget neutrality requirements on Medicaid waivers, which are the mechanism states use to experiment with program design. This would make it harder for states to get approval for waiver programs that increase federal spending, even if they expand access to care.
Moratoriums on Biden-Era Protections
Several provisions freeze or block regulations finalized during the Biden administration. These include rules related to eligibility and enrollment processes for Medicaid, CHIP, and Medicare Savings Programs, as well as staffing standards for long-term care facilities. The staffing rule, which would have required nursing homes to maintain minimum nurse-to-resident ratios, was one of the most significant nursing home reforms in years. The moratorium effectively shelves it.
Blocking the eligibility and enrollment rules is also significant. Those regulations were designed to make it easier for people to sign up for and keep Medicaid coverage by streamlining applications and reducing paperwork. Freezing them means states won’t be required to adopt those simplifications.
A New Home and Community-Based Services Option
Not every provision in the bill reduces coverage. One creates a new waiver option for Home and Community-Based Services, which help older adults and people with disabilities receive care at home rather than in institutional settings. The details of this option will matter enormously. Currently, more than 800,000 people nationwide sit on waiting lists for these services. Whether this new waiver pathway actually reduces those waitlists depends on its funding structure and requirements.
This provision exists against a backdrop of long-standing bipartisan interest in expanding home-based care. Earlier proposals from Democrats called for $400 billion in new federal funding for these services, which would have increased annual spending by at least 33%. The Big Beautiful Bill takes a different approach, creating a pathway but without comparable new funding.
What the Coverage Losses Would Look Like
The CBO’s projection of 7.8 million more uninsured people by 2034 reflects the combined effect of all these provisions. The losses wouldn’t happen overnight. Work requirements, eligibility redeterminations, reduced federal matching rates, and tighter verification would each remove people from the rolls incrementally over several years. Some of those people would find other coverage through employers or marketplace plans, but many would simply become uninsured, particularly adults with low incomes in states that might reverse their Medicaid expansions.
The 10 states that never expanded Medicaid already leave a “coverage gap” where adults earn too much for traditional Medicaid but too little for marketplace subsidies. If expansion states begin rolling back coverage due to reduced federal funding, that gap could widen dramatically, returning Medicaid closer to what it looked like before the ACA: a program limited primarily to children, pregnant women, and people with disabilities, with large groups of low-income adults left with no affordable option.