House Republicans on May 22 passed President Donald Trump’s “One Big Beautiful Bill” which proposes significant Medicaid cuts and ACA reforms that hospital leaders argue would leave millions without coverage and reduce access to care.
The 1,112-page bill also includes cuts to Medicare funding, new restrictions on federal loans for medical students and provisions to create a permanent, inflation-based mechanism for annual updates to Medicare physician payments.
The legislation now heads to the Senate, where it faces further debate from lawmakers and growing scrutiny from hospital leaders and other healthcare stakeholders. Further revisions may be in the cards as Republican leaders work to unify support and deliver the legislation to President Trump’s desk in the coming weeks.
Here are 23 things to know:
ACA
1. The legislation proposes several key changes to the ACA, including shortening the ACA open enrollment window by one month and eliminating automatic renewals, requiring individuals to reapply each year. It would also tighten restrictions on special enrollment periods, making it more difficult to obtain coverage outside of standard timeframes.
2. Beginning Jan. 1, 2027, ACA marketplace plans would be prohibited from covering gender transition procedures. The bill also bans Medicaid and CHIP funding for such care in minors.
3. The legislation would revise how ACA subsidies and out-of-pocket maximums are calculated, which the Congressional Budget Office projects would reduce financial assistance and increase out-of-pocket exposure for many enrollees.
4. States that have not expanded Medicaid under the ACA would receive higher federal payments, which could discourage expansion in nonparticipating states.
5. The bill would permit insurers to offer plans with higher deductibles and cost-sharing requirements, potentially reducing the value of coverage while raising net premiums for those who receive subsidies.
6. These policy changes come as the ACA’s enhanced premium tax credits are set to expire at the end of 2025. Without renewal, many marketplace enrollees will face significant increases in out-of-pocket premiums.
Medicare
7. A proposed staffing mandate is halted under the bill for long-term care facilities that receive Medicaid and Medicare funds.
8. The bill promotes the use of artificial intelligence to recover and reduce improper Medicare payments.
9. A May 20 report from the nonpartisan Congressional Budget Office found that the bill could cut nearly $500 billion over the next decade in Medicare funding.
10. The budget bill includes provisions to increase Medicare physician payments by an estimated 2.25% in 2026. This would be achieved by tying payments to 75% of the Medicare Economic Index. Starting in 2027, annual payments would be adjusted by 10% of the index, establishing a permanent, inflation-based update mechanism.
11. Under current law, physician pay is set to increase by just 0.25% in 2026 and 2.5% by 2035. The proposed changes would boost payments to 4.3% by 2035 instead. Physician groups including the American Medical Association strongly support the provision, calling it a critical step toward restoring stability after years of payment cuts.
12. The bill also adjusts the Medicare Physician Fee Schedule’s conversion factor, a key formula used to calculate final physician reimbursement. While the legislation introduces inflation-based updates, changes to the conversion factor could offset those increases and slow long-term payment growth. Physician groups have welcomed the update mechanism as a step in the right direction, though they say further reforms are needed to ensure physician payments fully reflect inflation and keep pace with rising practice costs over time.
Medicaid
13. The bill introduces a two-year acceleration of Medicaid work requirements for able-bodied adults ages 18 to 64, which is slated to take effect no later than Dec. 31, 2026, instead of 2029. States have the ability to implement these requirements earlier to secure quicker savings.
14. Beginning Oct. 21, 2027, states will be mandated to redetermine Medicaid eligibility every six months for people in the expansion population.
15. Medicaid and CHIP federal financial participation is prohibited under the bill revisions for people who fail to verify immigration status, citizenship or nationality in the designated “reasonable opportunity” window.
16. States will also be required to cross-check their Death Master File quarterly to confirm deceased individuals are disenrolled. Should errors occur, there will be reinstatement provisions.
17. The Social Security Act is amended to cut retroactive Medicaid coverage from three months to one month before the application date.
18. Federal Medicaid and CHIP funding is prohibited for “specific gender transition procedures” provided to people under 18 years of age.
19. Eligibility for increased federal medical assistance percentage for states that are newly expanding Medicaid will be wound down. To qualify, states must start expansion by Jan. 1, 2026 to restrict late expansion states from receiving an elevated match rate.
20. New rules for waiving the uniform tax requirement for Medicaid provider taxes will be imposed, which tightens conditions for states to use the financial tools.
Restrictions on federal student loans
21. The bill includes proposals that would significantly limit the amount of federal student loans medical students can borrow. Specifically, it calls for the elimination of the Grad PLUS loan program, which allows graduate students to borrow up to the full cost of tuition and living expenses.
22. Federal loans for students in graduate and professional programs would be capped at $100,000 and $150,000, respectively. In 2024, more than 70% of medical school students graduated with education debt. The average debt amount that year was $212,341, according to the Association of American Medical Colleges. In its current form, the bill also excludes loan repayments made during residency years from counting toward Public Service Loan Forgiveness.
23. Hospitals and medical schools are urging Congress to oppose the provisions, warning they could deter students from entering the field and exacerbate the nation’s physician shortage.
