Will Trump’s ‘big, beautiful bill’ put 12 million people at risk of losing Medicaid? Here’s what you need to know

US President Donald Trump’s ‘big, beautiful’ tax cut and spending bill has been passed in both the House and the Senate. As part of its provisions, it is expected to bring sweeping changes to the government's Medicaid healthcare program, which covers about 71 million low-income people in the United States. The earlier policies, from the Biden and Obama administrations, aimed at easier access to healthcare for millions.

According to the Congressional Budget Office estimates, nearly 12 million more people to be without insurance by 2034 after Trump signs the legislation due to reductions in federal support for Medicaid and Affordable Care Act. This would undermine the finances of hospitals, nursing homes, and community health centres, as they will need to absorb more costs of treating uninsured people. Some may cut on services and employees, while some may even shut down.

Here are key healthcare provisions under the bill:

Mandatory work

Currently, Medicaid enrollees are not subject to work requirements. Under the new bill, Medicaid enrollees would have to work, do community engagement activities or attend school for a minimum of 80 hours to qualify for the programme. They will have to regularly file paperwork, ensuring they are meeting the new requirements, which are set to start in January 2027. This would end coverage of millions of people who do not meet the new standards.

More frequent checks for eligibility

The states will be required to conduct a check to see if people still qualify for Medicaid twice a year instead of once. This would affect about 20 million people who got enrolled through the Affordable Care Act (ACA) expansion, which includes those making around $21,600 a year or less in 2025. The new bill would also prevent people from being eligible to sign up for Medicaid in more than one state at the same time.

Stricter rules for states

Money raised for the Medicaid programme was often raised from taxes imposed on hospitals and healthcare providers until now. The new bill would restrict how much money states can collect from these taxes. It would also impose stricter rules about which services can be taxed and how the money is distributed across providers. This could make it harder for states to get extra federal money, which may lead to funding cuts, especially in rural areas. Although the bill includes a $50 billion fund for rural hospitals.

Immigrants rules

Mediciad is currently eligible for some immigrants who are legally in the US after a five-year wait. However, under the new bill, refugees, some abused spouses and children, and people granted asylum will not be eligible.

Cost-sharing requirements

Currently, Medicaid gives states an option to charge nominal co-payments for people with incomes over 150 per cent of the federal poverty level. The new bill would mandate co-pays for people earning more than 100% of the federal poverty level, which would reach up to $35 per medical service, with some exemptions including emergency and preventive care.