WASHINGTON — Republicans’ sweeping domestic policy package, now heading to President Trump’s signature after narrowly passing the House, delays some of its most significant healthcare spending cuts until after the 2026 midterm elections. This could lead to major changes in Medicaid and Affordable Care Act enrollment, potentially leaving millions with reduced or lost coverage.
Under the plan, which pairs early tax breaks with delayed safety-net cuts, Medicaid work requirements would take effect nationwide after the elections, mandating that most adults with children over the age of 14 meet employment thresholds to retain coverage. States will also face tighter restrictions on how they finance Medicaid, with phased reductions in federal funding starting in 2028, likely forcing states to cut payments to providers, reduce eligibility, or make other difficult budget trade-offs.
States will be under enormous pressure to redesign systems to track work hours and exemptions for millions, according to many current and former state officials, who warn that even states inclined to implement the policy may struggle to meet the timeline, as reported by the New York Times.
At the same time, the bill imposes new administrative hurdles on ACA marketplace enrollment, including an end to auto-renewals and new paperwork requirements. These changes, set to begin as soon as this fall’s enrollment period, could lead to lower enrollment and higher premiums, prompting some insurers to exit specific markets.
Advocates warn that the combination of increased paperwork, loss of auto-renewal, and future cuts will particularly impact low-income families and individuals with chronic health conditions. “They want to try to get past elections and try to hide the ball on the damage they’re imposing on health care and food assistance,” said Alex Jacquez of Groundwork Collaborative, a progressive policy group.
The nonpartisan Congressional Budget Office has previously warned that Medicaid work requirements could lead to hundreds of thousands losing coverage each year due to compliance challenges, even among those who are working.
While the tax cuts in the package are projected to increase the federal deficit by over $3 trillion by 2034, the safety-net cuts are intended to offset some of that cost. However, healthcare experts argue that patients and hospitals will ultimately bear the real cost. Hospitals, particularly those in rural and safety-net facilities, are likely to face increased uncompensated care costs if coverage losses accelerate, further straining the health system.
As Republicans prepare to celebrate the tax cuts’ early impact during the upcoming election cycle, health systems, state Medicaid agencies, and patients are bracing for the longer-term effects that could reshape healthcare access in the U.S. well into the next decade.
