Part 1: The Big Ugly Bill

What in the Health?! July 12, 2025

Well. It’s been an interesting last few weeks. Just when I think the pace of the destruction is slowing down (perhaps because it’s all rubble already?) this administration proves me wrong.

I’m going to break this into 2 installments to make it all easier to read and digest. Here’s installment 1:

1. The Big Ugly Bill is now law.

There’s lots I could say about this bill, of course. It is not beautiful, no matter how they want to title it. It makes clear that our lawmakers don’t care about the average American, because their lives are going to get a lot worse, and the damage of this bill will continue to be felt for many, many years. It might be a decade before the damage starts to really become apparent.

Why is that? It’s built that way. It’s designed to delay the damage caused until after the 2026 midterms, because lawmakers are clear that if the pain is felt before the midterms then incumbents will get hammered. Medicaid work requirements? Not going into effect until December 2026. Requiring people to prove their eligibility for Medicaid every 6 months? December 2026. Increased burden on states to prevent food insecurity by paying more for SNAP funding? Starts in 2027. States having the option to charge people on Medicaid premiums or co-pays? 2028.

The Common Health Coalition already produced a great report summarizing the impacts of the public health cuts baked into this new law, which you can read here.

Here’s an excerpt summarizing the three primary categories of impact overviewed in the report:

1. Fewer services available to patients and clinicians – Cuts to services like tobacco quitlines, newborn screenings, and public health laboratories (PHLs) will directly affect what clinicians can offer and what patients can access.

2. More patients arriving sicker and at higher cost – Eliminating prevention programs will result in delayed diagnoses, increased disease prevalence, and costly outbreaks, such as current HIV and measles outbreaks.

3. Health care forced to fill gaps or go without – As public health functions like contact tracing, mental health support, or tuberculosis treatment diminish, health systems and health plans will face difficult decisions: whether to backfill services on their own dime or leave them unaddressed.

Across all three categories, consequences will fall most heavily on underserved communities, rural areas, and people already facing barriers to care.

But in addition to all of that, let’s talk more about cuts to Medicaid. Why have we been hearing some much about Medicaid? As a reminder, 78 million people in the United States (1 in 4 people) currently access our expensive healthcare system via Medicaid. People are eligible for Medicaid coverage if they have low or limited income, have certain disabilities, are pregnant, or are older adults (age 65+) needing long-term care. Children can also qualify for Medicaid, even if their parents don’t. Many children with special needs and many adults suffering from chronic illnesses rely on Medicaid to access the care they need. Millions of elderly Americans rely on Medicaid to cover their long-term care. Hospitals, particularly in rural and low-income communities, rely heavily on Medicaid reimbursements to keep their doors open—especially since in many cases they are obligated to provide care even if someone has no insurance and can’t pay for it (as it should be; we don’t want anyone turned away from a hospital for life-saving care just because they can’t afford it).

Kaiser Family Foundation did a digestible summary of the Congressional Budget Office’s analysis on the impacts of this new bill. They found that after accounting for the population of each state, the risk of hospital closures is 1.7 times higher for people living in red states (216 hospitals at risk for closure) compared to blue states (122 hospitals at risk for closure). Across all states, that’s 337 million people served by 338 hospitals that might not be open much longer—and in most of these places that means those millions of people will have to travel much further for hospital-based care. This includes heart attacks, strokes, car accidents, advanced cancer treatments, and more.

Mostly, the way the cuts are achieved (to cover huge tax cuts for the wealthy, let’s not lose sight of that) is by assuming that millions of people will fail to maintain coverage on Medicaid because they won’t be able to properly complete all the complex paperwork, or jump through the other hoops to stay on the rolls. Does it make your blood pressure jump when you think about trying to renew your license at the DMV, just imagining that DMV employee telling you that you didn’t bring the right form and have to go away and come back again? This is the type of thing people are going to have to start dealing with every six months. It’s built to be painful.

You might be thinking “I don’t know, I think this is good because there’s so much fraud with Medicaid, and that’s the purpose of this whole thing—to clean that up. Why should I pay more taxes so other people can take advantage of the system?” You could be forgiven for thinking that, because those are the talking points that have been repeatedly shouted from the rooftops. But it’s simply wrong.

Did you know that adults with Medicaid spend 27% less, on average, than adults with private insurance, even though their health is worse overall? They also have fewer outpatient visits, and use fewer prescription drugs than people on private insurance. The idea that people on Medicaid commit fraud to get free healthcare is also incorrect. In fact, per the Department of Justice press release on June 30 entitled “National Health Care Fraud Takedown Results in 324 Defendants Charged in Connection with Over $14.6 Billion in Alleged Fraud: Largest Justice Department Health Care Fraud Takedown in History More than Doubles Prior Record of $6 Billion,” not a single case was a Medicaid (or Medicare) beneficiary committing fraud. Almost all of them were a medical provider or other person taking advantage of Medicaid or Medicare beneficiaries by providing services they didn’t need or never even received.

While we’re busting myths you’ve probably heard 1000 times as talking points, 2 out of 3 people covered by Medicaid already work. The remaining 36% can’t work because they’re a full-time caregiver (12%), have a serious illness or disability (10%), or are in school (7%)—that leaves only 8% who aren’t working for another reason. So creating onerous work requirements to force people to work full-time or lose Medicaid is unnecessary and will just create further hardships for people who have limited income and in many cases are already in a very tough spot.

It's too late to prevent this, now. Our lawmakers already let this become law, and it’s substantially reshaped our healthcare system for the foreseeable future. But we can show them what we think about that come midterms, that’s for sure. And in the meantime, try to show some compassion for your neighbors, colleagues, family members, or friends who may now be extra stressed about how they’ll access necessary healthcare for them and their loved ones in the future.