With an ultimate goal of democratizing health coverage to vulnerable Americans, President Lyndon B. Johnson signed into law the Social Security Amendments of 1965, creating two major programs: Medicare, which focused on seniors; and, more pertinently, Medicaid, which would prioritize low-income Americans. Medicaid covers various forms of medical attention, from hospital and physician care to nursing facility and X-ray services; for people under 21, this package is even more robust, promising a regular interval of check-ups and adequate follow-up care.
Over 70 million Americans benefit from this program today— some may not receive health coverage from their employers, while others may not have a job at all, but Medicaid gives an avenue for all to have basic health standards met without having to fully pay for insurance in a much more expensive private market. Ideally, as economic strife arises, Medicaid should expand its reach to protect as many people as possible
However, with the passing of the far-reaching One Big, Beautiful Bill Act (OBBBA) on July 4, 2025, Medicaid’s accessibility is taking a hit, which may debilitate health support and outcomes for a large share of America.
Arguably, the most contentious OBBBA-induced change to Medicaid is a new work requirement: for adults between ages 19 and 64, a minimum of 80 hours per month of employment, service, or other equivalent activities must be reported in order to qualify for Medicaid. There are exceptions— parents of children under 13 or individuals deemed medically frail may not lose eligibility despite being unqualified— but largely, Medicaid enrollees must meet these new standards.
Though the intent is to increase employment among the poorest Americans, a work requirement may contradict the very philosophy of Medicaid— to provide coverage for Americans in financial hardship, including those without employment.
Nevertheless, the idea of implementing work requirements for Medicaid eligibility is not a new concept: on the state level, over ten states have striven to enforce some form of one. Many advances were overturned by judges who claimed that they ran contrary to the principles of Medicaid; others received clearance but haven’t been followed through with. In 2018, however, Arkansas became the first state to successfully implement a work requirement for Medicaid.
Much like OBBBA, Arkansas’ plan was to encourage low-income adults to more aggressively pursue employment or civic engagement. Contrary to expectation, multiple studies found no association between this new work requirement and employment among the poorest Arkansans. Instead, over 18,000 people consequently lost their Medicaid coverage within four months of the work requirement implementation. The obligation was eventually removed in early 2019.
It’s only fair to speculate that even more drastic coverage loss may be imminent for a federally mandated version of this restriction, especially with Arkansas’ recent experiment with an identical idea and motive. OBBBA’s work mandate posits that many unemployed Americans don’t work by choice, but this assumption may render job-seeking Americans even more financially vulnerable.
Another major change from OBBBA stipulates that enrollees be reviewed biannually for eligibility, an increase in reviews from the old, annual review. This change complicates administrative procedures for enrollees: it increases the possibility that completely eligible Americans don’t receive Medicaid simply because they’re unable to report the necessary information, which may especially become a concern for rural Americans, as well as other people who may have weaker or no access to Internet connection.
Unsurprisingly, OBBBA has also introduced funding cuts to Medicaid. Over the next ten years, an estimated $1 trillion is to be cut, a development that trickles administrative pressure all the way down to the state level. States are responsible for maintaining local Medicaid programs while also allocating funds among other basic priorities. With less Medicaid-directed funding, some states could narrow eligibility requirements; discontinue Medicaid expansion efforts; or even pull money from hospitals and clinics, indirectly or directly. Of course, with a more limited medical scope, demand shifts onto emergency rooms and charitable health clinics, which already face high demands.
By 2037, a projected 7.8 million Americans will be without Medicaid due to OBBBA. Many of them, lacking job-secured health coverage or jobs at all, may be uninsured. That could mean no regular access to check-ups, no comfortable way to get diagnostic screenings, no vision care, and much more. The uninsured will be much more susceptible to medical debt, which, paired with a tight budget, can be a disastrous financial situation with little way out.
Meanwhile, states could disinvest in their medical facilities in order to save money, ultimately shutting down some facilities and overworking the ones that survive. When it comes to critical tasks like issuing vaccinations or taking care of people efficiently in the emergency room, hospitals and clinics may be less accessible and have compromised work quality. Certainly, OBBBA could reshape the American healthcare scene— rapidly in some areas, incrementally in others, but certainly overall.
Image Credit: The Seattle Times
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