Health · Oct 3, 2026The Aftermath of the Big Beautiful Bill, Part 1 of 5: The Law and Medicaid

The Aftermath of the Big Beautiful Bill · Part 1 of 5 · October 3, 2026, 12:08 PM CDT

Key Facts

• The One Big Beautiful Bill Act (Public Law 119-21) became law on July 4, 2025.^[1]
• The Congressional Budget Office estimates its Medicaid provisions cut federal Medicaid spending by $989.7 billion over ten years and leave 7.5 million more people uninsured in 2034.^[1]
• Medicaid work requirements start by December 31, 2026, or sooner if a state chooses.^[1]
• Peer-reviewed studies of Arkansas’s 2018 work requirement found coverage losses and no gain in employment.^[2]

The aftermath of the Big Beautiful Bill is not a single event. It is a calendar, and the first dates on it arrived two days ago.

On October 1, 2026, several Medicaid changes took effect. More are scheduled through 2028, and the biggest one for working-age adults begins by the end of this year.

This is Part 1 of a five-part series. Each part goes through the programs the law touched, what the research says, and what you can do. We lean on peer-reviewed studies wherever they exist and say so when they do not.

The five parts

1. Part 1 (today): the law’s overview and Medicaid.
2. Part 2: SNAP and food assistance.
3. Part 3: marketplace coverage, Medicare and rural health.
4. Part 4: student aid and education.
5. Part 5: taxes, energy and housing, plus a full citizen’s checklist.

Parts 2 through 5 will be built from sources we read in full, the same way as this one.

1. What the law changed in Medicaid

The Congressional Research Service counts health provisions that touch Medicaid, the Children’s Health Insurance Program, Medicare, private insurance and rural hospitals.^[1]

CBO estimates the health provisions together cut federal spending by $1.1 trillion over ten years. It estimates they leave 10.0 million more people without insurance in 2034.^[1]

Most of that comes from Medicaid. These are the pieces that matter to households:

• Work requirements. Adults 19 through 64 in the ACA Medicaid expansion group must complete at least 80 hours a month of work, a work program, community service or half-time education. Income equal to the federal minimum wage times 80 hours also counts. The requirement starts December 31, 2026, or sooner at a state’s option. The federal government may not waive it.^[1]
• Consequences. People who do not comply are denied or disenrolled. The law also bars them from federal subsidies to buy marketplace coverage.^[1]
• Six-month checks. From January 1, 2027, states must re-check expansion adults’ eligibility every six months instead of every twelve.^[1]
• Immigrant eligibility. From October 1, 2026, federal Medicaid money cannot cover people outside a short list: citizens and nationals, lawful permanent residents, Cuban and Haitian entrants, and people from certain Pacific compact nations.^[1]
• Provider taxes. From fiscal years starting October 1, 2026, states cannot add new provider taxes. Rates in expansion states then step down from 5.5% in FY2028 to 3.5% in FY2032.^[1]
• State-directed payments. Grandfathered payments shrink by 10 percentage points a year from January 1, 2028, until they reach 100% of Medicare rates in expansion states.^[1]
• Rural hospitals. The law creates a $50 billion Rural Health Transformation Program: $10 billion a year for FY2026 through FY2030.^[1]

RAND researchers describe the law’s stated aims as cutting federal spending and improving program integrity. They built state-level estimates of the Medicaid money and enrollment effects through 2034.^[7]

2. What the evidence says about work requirements

Arkansas was the first state to try them. From June 2018, adults 30 to 49 had to work 20 hours a week, join community activities or qualify for an exemption.^[2]

By April 2019, when a federal judge halted the policy, 18,000 adults had lost coverage.^[2]

The researchers surveyed 2,706 low-income adults in Arkansas and three comparison states. Their peer-reviewed findings, published in Health Affairs in 2020:^[2]

• Work requirements did not increase employment over eighteen months.
• Among people who lost Medicaid, 50% reported serious problems paying off medical debt. 56% delayed care because of cost, and 64% delayed taking medications.
• More than 70% of Arkansans were unsure whether the policy was even in effect.

An earlier paper from the same team in the New England Journal of Medicine looked at the first year. It reported that many people lost coverage because of confusion and red tape.^[3]

Two cautions apply. Arkansas’s rule is not the federal rule: the new law covers more adults, sets 80 hours a month, lists many exemptions and checks every six months. And these are studies of one state’s experiment. They are strong evidence about what happened there, not a forecast for every state.

3. What Medicaid coverage itself does

The best randomized evidence comes from Oregon, where a 2008 lottery offered Medicaid to some low-income adults and not others.^[4]

Two years later, researchers compared 6,387 adults offered coverage with 5,842 who were not. Coverage lowered the chance of a positive depression screen by 9.15 percentage points. It “nearly eliminated catastrophic out-of-pocket medical expenditures.”^[4]

The same study found no significant improvement in measured blood pressure, cholesterol or glycated hemoglobin within two years.^[4] We include that because it cuts the other way, and a fair reading needs both findings.

4. What the projections say, and why they differ

In June 2025, three researchers modeled the House version of the bill in the Annals of Internal Medicine. Their mid-range estimate was 7.6 million more uninsured people and 16,642 additional deaths a year.^[5]

That is a projection of a bill that changed before it became law. CBO’s estimate for the enacted law is 10.0 million more uninsured people in 2034.^[1] The two numbers use different bills and methods, so do not add them or treat one as a correction of the other.

A 2026 commentary in Psychiatric Services warns that people with serious mental illness may be among those most at risk. It points out that symptoms and paperwork do not mix well, and that harm can reach people who qualify for an exemption but cannot document it.^[6]

5. Who is exempt

The law lists the exemptions. Check this list before anything else.^[1]

Watch: how the work requirement could reach families

Video: NBC News — how the new Medicaid work requirements could affect families with disabled children.

What is not yet known

• Each state decides how people will report hours and prove an exemption. Those rules are still being set.
• We have no peer-reviewed measurement yet of how the enacted law works in practice. The studies above look at Arkansas’s past policy or project future effects.
• CBO’s figures are estimates. Actual enrollment will depend on state choices and the economy.

What You Can Do Right Now

The Arkansas research found that confusion and red tape drove much of the coverage loss.^[2][3] So the most useful steps are about paperwork.

1. Find your state’s start date. The federal deadline is December 31, 2026, but a state may start sooner. Ask your state Medicaid agency.
2. Check whether you are exempt. Use the list above. If you qualify, ask how your state wants you to prove it.
3. Update your contact information with your Medicaid agency now, so notices reach you.
4. Open and answer every notice. Missing one was a common way people lost coverage in Arkansas.
5. Keep records. Save pay stubs, volunteer logs, school enrollment and medical documentation.
6. Mark your calendar for six-month checks starting January 1, 2027 if you are an expansion adult.
7. Know the cost of losing coverage. Under the law, someone dropped for not meeting the requirement cannot get federal marketplace subsidies.
8. Ask for help early. Community health centers and legal aid offices often help with benefit paperwork. Call your state agency’s help line if you are unsure.
9. Tell your state officials what is working and what is not. States are still writing the rules.

How to Verify This Yourself

• Open the Congressional Research Service report and search for “community engagement” and “Section 71107.”
• Look up each journal article by its link below and read the abstract.
• Compare the Annals projection (House bill) with CBO’s number (enacted law).

References

1. Congressional Research Service, “Health Provisions in P.L. 119-21, the FY2025 Reconciliation Law,” R48633, August 18, 2025. Primary (nonpartisan congressional analysis; reports CBO estimates). congress.gov
2. Sommers BD, Chen L, Blendon RJ, Orav EJ, Epstein AM. “Medicaid Work Requirements In Arkansas: Two-Year Impacts On Coverage, Employment, And Affordability Of Care.” Health Affairs, September 2020. Primary (peer-reviewed). healthaffairs.org
3. Sommers BD, Goldman AL, Blendon RJ, Orav EJ, Epstein AM. “Medicaid Work Requirements: Results from the First Year in Arkansas.” New England Journal of Medicine, June 19, 2019. Primary (peer-reviewed). nejm.org
4. Baicker K, Taubman SL, Allen HL, et al. “The Oregon Experiment: Effects of Medicaid on Clinical Outcomes.” New England Journal of Medicine, 2013. Primary (peer-reviewed randomized study). nejm.org
5. Gaffney A, Himmelstein DU, Woolhandler S. “Projected Effects of Proposed Cuts in Federal Medicaid Expenditures on Medicaid Enrollment, Uninsurance, Health Care, and Health.” Annals of Internal Medicine, June 17, 2025. Primary (peer-reviewed projection of the House bill, not the enacted law). acpjournals.org
6. Frank RG. “Medicaid Reforms in the One Big Beautiful Bill Act and Mental Health Care.” Psychiatric Services, 2026. Secondary (peer-reviewed commentary). psychiatryonline.org
7. Rao P, Baker L, Girosi F, Li E, Kerber R, Eibner C. “State-Level Impacts of Key Medicaid Provisions in the One Big Beautiful Bill Act.” RAND Health Quarterly, 2026. Primary (peer-reviewed projection; we read the abstract only). doi.org

Investigative methodology: the law’s provisions and CBO figures were read from the CRS report. Study findings were read from the published abstracts of each paper. Quotation marks mark exact wording. We did not use figures we could not read directly.

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