On July 4, 2025, President Trump signed H.R. — Plain English Decode
On July 4, 2025, President Trump signed H.R. 1, the Reconciliation Bill (aka the "One Big Beautiful Bill Act") into law, which includes significant policy changes to Medicaid and the Health Insurance Marketplaces.
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What It Does
This act reduces taxes, reduces or increases spending for various federal programs, increases the statutory debt limit, and otherwise addresses agencies and programs throughout the federal government. The bill operates on two levels: tax changes and healthcare/spending changes. On taxes, the TCJA personal income tax rates and brackets are now permanent. The seven (7) brackets are 10%, 12%, 22%, 24%, 32%, 35%, and 37%. The temporary TCJA standard deduction amounts ($15,750 for individual filers, $31,500 for joint filers, and $23,625 for heads of households) are made permanent. The Child Tax Credit is made permanent. The credit increases to $2,200, subject to a phaseout. The 100% bonus depreciation provisions of the TCJA are now permanent. The Qualified Opportunity Zone (QOZ) program is now permanent with some modifications.
On healthcare, the bill reshapes Medicaid dramatically. One source of the law's Medicaid cuts is a 10-year moratorium on implementation or enforcement of provisions in two rules finalized by the Biden administration that would have reduced administrative burdens to make it easier for people to enroll in and maintain Medicaid and CHIP coverage. In effect, the law delays or pauses implementation of many provisions in the two rules until October 2034. Congress enacted cuts of approximately $1.15 trillion on federal health care spending over the next decade. The final version of the bill included further constraints on state Medicaid financing and eligibility and significantly scaled back Marketplace subsidies for certain populations. The work requirement mandate (Section 71119) becomes effective January 1, 2027, requiring states to verify work participation of 80 hours per month for non-exempt adults 19-64. H.R. 1, the 2025 reconciliation legislation signed by the President on July 4, 2025, increased the debt limit by $5 trillion.
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The Real Story
This bill is fundamentally about a tradeoff: The Senate-passed bill includes significant tax law changes, increased funding for immigration control and national defense, and spending reductions affecting Medicaid and a large number of other federal programs. Republicans, backed by business groups and conservative organizations, wanted to lock in tax cuts permanently and increase spending on border security and military. Every Senate Democrat voted against the measure. Republican Sens. Susan Collins of Maine, Rand Paul of Kentucky and Thom Tillis of North Carolina joined Democrats and voted against the bill. Democrats argued this deepened inequality by cutting healthcare for millions while providing large tax benefits to corporations and wealthy individuals.
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Who Benefits
- High-Income Earners and Wealth Holders: The Child Tax Credit is made permanent. The credit increases to $2,200, subject to a phaseout. The phaseout begins at an income of $200,000 for single filers and $400,000 for joint filers. The Joint Committee on Taxation estimates that Senate Republicans' proposal will cost $4.45 trillion, but despite the price tag, the legislation primarily helps billionaires at the expense of American working families. In fact, this legislation would provide a huge, permanent tax cut of nearly $350,000 for multimillionaires and billionaires while people earning $40,000 a year will see a comparatively meager average tax decrease of $442 per year.
- Corporations and Business Owners: The section 179 expensing provision cap is now $2.5 million, indexed for inflation. The 100% bonus depreciation provisions of the TCJA are now permanent. The Qualified Opportunity Zone (QOZ) program is now permanent with some modifications.
- Defense Contractors and Border Security Companies: The package also included boosts to border funding, extended tax cuts and made policy changes to immigration, energy and defense.
- Married Couples and Parents with Children: The child tax credit allows eligible taxpayers to reduce their federal income tax liability by up to $2,200 per qualifying child (indexed to inflation). If their tax liability is less than the value of their child tax credit, they may be eligible for a refundable credit calculated using the earned income formula. This benefits middle-income families with children, though the full benefit phase-out at $400,000 for married couples.
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Who Gets Hurt
- Medicaid Recipients Aged 19-64 in Expansion States: H.R. 1 mandates that Medicaid members aged 19-64 who are covered through the Affordable Care Act Medicaid expansion or an 1115 demonstration waiver that provides minimum essential coverage must engage in employment, education, a work program, or community service to maintain their Medicaid eligibility. Millions of working-poor adults—including those with disabilities, caregivers, and underemployed workers—face coverage loss if they cannot document 80 hours/month of work.
- Rural Healthcare Providers and Communities: In northeast Georgia, a hospital closed its maternity ward. In rural New Hampshire, a community health center shuttered. And in Iowa, a Des Moines hospital system laid off dozens of employees and closed a clinic. Rural health providers that rely on Medicaid funding were already under strain before the bill cut federal health spending by hundreds of billions of dollars over the next decade. Rural communities may face increased health risks as deep Medicaid cuts strain the finances of rural hospitals, while the bill's $50 billion health fund covers only a fraction of the expected shortfall.
- Children and Pregnant Women: Child enrollment in Medicaid and CHIP grew from 35.2 million in February 2020 to a high of 42.3 million during the COVID-era enrollment protections but dropped to 37.3 million by April 2025. Enrollment declines for children are expected to continue for a variety of reasons, and pressure on state eligibility systems will make it slower and harder for eligible children to regain Medicaid coverage.
- Immigrants: The legislation includes an estimated $863 billion in budget cuts for Medicaid and $295 billion in cuts for the Supplemental Nutrition Assistance Program (SNAP) for fiscal years 2025 to 2034. The law strips coverage from many lawfully residing immigrants.
- SNAP Recipients: The legislation includes an estimated $863 billion in budget cuts for Medicaid and $295 billion in cuts for the Supplemental Nutrition Assistance Program (SNAP) for fiscal years 2025 to 2034. The combined cuts exceed $1 trillion.
- Marketplace Health Insurance Buyers: Unless Congress extends those subsidies before December 2025, Marketplace enrollees will face steep premium hikes with CBO estimating that 4.2 million will become uninsured.
- Low-Income Workers (General Tax Impact): While the bill cuts income taxes for most earners, there is also some confusion on the impact of the bill on the amount most people would pay in taxes. The House version of the bill is expected to cut taxes for most Americans, but four in ten (38%) think it would increase taxes, 21% correctly say it would decrease taxes, and about four in ten saying the tax rate would either not be changed (15%) or they are not sure (25%).
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Red Flags
- Massive Coverage Loss with Minimal Safeguards: The Congressional Budget Office estimates the law will cut federal Medicaid spending by $911 billion over 10 years and will increase the number of people who are uninsured by 10 million in 2034. Other estimates are higher: The nonpartisan Congressional Budget Office (CBO) estimates that these cuts will result in 11.8 million individuals directly losing their health insurance coverage under Medicaid, and an additional roughly 3.1 million people losing Medicaid coverage under marketplace plans. By the government's own estimates, these cuts will result in the loss of health coverage for 17 million Americans, including some of the country's most vulnerable populations—children, pregnant women, disabled individuals, seniors, and veterans.
- Rushed Work Requirements with Uncertain State Implementation: The enactment of H.R.1 establishes mandatory work reporting requirements for certain Medicaid enrollees, marking the first federal mandate making Medicaid eligibility conditional on work or other qualifying activities in the program's history. Beginning January 1, 2027, states must implement these requirements for "applicable individuals" ages 19 through 64 who are enrolled in Medicaid expansion or equivalent coverage. H.R. 1 requires certain Medicaid beneficiaries to demonstrate that they work or are in a work program, are enrolled in school, or complete community service for 80 hours a month to stay enrolled in the program. States must build new verification systems in 18 months with inadequate federal guidance—CMS is required to issue an Interim Final Rule to implement these requirements by June 6, 2026, which will likely include additional operational details and may introduce new policy considerations for states implementing the community engagement requirements.
- Ballooning Deficit Despite Massive Cuts: CBO and the staff of the Joint Committee on Taxation estimate that enacting the bill would increase deficits over the 2025–2034 period by $2.4 trillion, excluding any macroeconomic or debt‑service effects. That change stems from a reduction in revenues of $3.7 trillion and a reduction in outlays of $1.3 trillion over the 2025–2034 period. CBO estimates that the additional debt-service costs under the bill would total $551 billion over the 10-year period. CBO estimates that debt-service costs under H.R. 1, the One Big Beautiful Bill Act, would total $551 billion over the 2025–2034 period—increasing the bill's cumulative effect on the deficit to $3.0 trillion.
- Administrative Burden Falls on States Facing Funding Cuts: Many of these, including work requirements and more frequent eligibility redeterminations, will create greater administrative burden and costs for states, just as they are facing federal funding cuts. States must verify work compliance, send notifications, and hear appeals—all without proportional federal funding. Rural states face particular strain.
- $5 Trillion Debt Ceiling Increase with No Corresponding Deficit Reduction: H.R. 1, the 2025 reconciliation legislation signed by the President on July 4, 2025, increased the debt limit by $5 trillion. This is not a procedural matter—it means Congress authorized $5 trillion in additional borrowing, yet the bill itself only offsets a tiny fraction of its cost through spending cuts.
- Sunset of Tax Benefits Creates Hidden Time Bombs: Another concern is the temporary nature of many of the bill's benefits. Several tax breaks and credits are set to phase out after 2028, which critics say undermines the bill's long-term stability and creates uncertainty for families and businesses planning for the future. This sunset clause raises questions about whether the bill is a sustainable solution or a short-term political maneuver.
- Medicaid Eligibility Rule Rescission Targets Seniors and Disabled: CBO has previously estimated that by itself, rescinding the rule would cut Medicaid enrollment by 2.3 million people in 2034. Based on CMS' regulatory impact analysis, most of those losing Medicaid coverage would likely be seniors and people with disabilities also enrolled in Medicare. Earlier preliminary CBO estimates indicate that 1.3 million people who are dually eligible for Medicare and Medicaid would lose their Medicaid coverage under the bill.
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Hidden Riders
- Regulatory Bypass for Medicaid Work Requirements: H.R. 1 requires the Secretary to promulgate an interim final rule for purposes of implementing the community engagement policy no later than June 1, 2026. This rule and any subsequent amendments are explicitly exempt from formal notice and comment rulemaking outlined at 5 U.S. Code § 553. This means HHS can implement the rule without the normal public comment period, eliminating accountability for how the rule is written.
- Medicare GLP-1 Bridge Program: The Medicare GLP-1 Bridge program will start on July 1, 2026. Through this short-term demonstration, CMS will be expanding access to certain GLP-1 medications to eligible Medicare Part D beneficiaries who do not currently have access to these medications through the Part D benefit. This was buried in the bill as a temporary program but creates political cover for addressing weight-loss drug access debates.
- State Plan Amendment Authority for Work Requirements: These requirements cannot be waived under Section 1115, though states may request "good faith" exemptions through 2028. This strips away traditional waiver authority, forcing compliance even if states identify harms to vulnerable populations.
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Current Status
On May 22, 2025, the U.S. House of Representatives passed H.R 1, the One Big Beautiful Bill Act, by a vote of 215-214. The Senate on July 1 voted 51 to 50 to pass an amended version of H.R. 1, the "One Big Beautiful Bill Act." The bill was approved with the tie-breaking vote of Vice President JD Vance and the support of all Senate Republicans, except for Senators Susan Collins (R-ME), Rand Paul (R-KY), and Thom Tillis (R-NC) who opposed the bill along with all Senate Democrats. President Donald J. Trump on July 4 signed into law H.R. 1, the "One Big Beautiful Bill Act." The bill was passed by the House on July 3 by vote of 218 to 214. The bill is now law. The next major event is June 1, 2026, when CMS must issue the interim final rule on Medicaid work requirements. States will then scramble to build implementation systems for a January 1, 2027 deadline. Legal challenges will likely begin in fall 2025 or early 2026. The healthcare provisions will begin affecting enrollment in late 2026 when state systems go live with new eligibility rules.
On July 4, 2025, President Trump signed H.R. 1, the Reconciliation Bill (aka the "One Big Beautiful Bill Act") into law, which includes significant policy changes to Medicaid and the Health Insurance Marketplaces.
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Why now
The bill permanently extends individual, business, and international tax provisions enacted as part of the 2017 TCJA that were set to change at the end of 2025. The One Big Beautiful Bill Act is a U.S. federal statute passed by the 119th United States Congress containing tax and spending policies that form the core of President Donald Trump's second-term agenda. Republicans controlled both chambers and moved quickly in spring 2025 to prevent expiration of the 2017 tax cuts and advance their spending and policy priorities before potential losses in the 2026 midterms.
The real story
This bill is fundamentally about a tradeoff: The Senate-passed bill includes significant tax law changes, increased funding for immigration control and national defense, and spending reductions affecting Medicaid and a large number of other federal programs. Republicans, backed by business groups and conservative organizations, wanted to lock in tax cuts permanently and increase spending on border security and military. Every Senate Democrat voted against the measure. Republican Sens. Susan Collins of Maine, Rand Paul of Kentucky and Thom Tillis of North Carolina joined Democrats and voted against the bill. Democrats argued this deepened inequality by cutting healthcare for millions while providing large tax benefits to corporations and wealthy individuals.
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Red flags
▸ Massive Coverage Loss with Minimal Safeguards: The Congressional Budget Office estimates the law will cut federal Medicaid spending by $911 billion over 10 years and will increase the number of people who are uninsured by 10 million in 2034. Other estimates are higher: The nonpartisan Congressional Budget Office (CBO) estimates that these cuts will result in 11.8 million individuals directly losing their health insurance coverage under Medicaid, and an additional roughly 3.1 million people losing Medicaid coverage under marketplace plans. By the government's own estimates, these cuts will result in the loss of health coverage for 17 million Americans, including some of the country's most vulnerable populations—children, pregnant women, disabled individuals, seniors, and veterans.
▸ Rushed Work Requirements with Uncertain State Implementation: The enactment of H.R.1 establishes mandatory work reporting requirements for certain Medicaid enrollees, marking the first federal mandate making Medicaid eligibility conditional on work or other qualifying activities in the program's history. Beginning January 1, 2027, states must implement these requirements for "applicable individuals" ages 19 through 64 who are enrolled in Medicaid expansion or equivalent coverage. H.R. 1 requires certain Medicaid beneficiaries to demonstrate that they work or are in a work program, are enrolled in school, or complete community service for 80 hours a month to stay enrolled in the program. States must build new verification systems in 18 months with inadequate federal guidance—CMS is required to issue an Interim Final Rule to implement these requirements by June 6, 2026, which will likely include additional operational details and may introduce new policy considerations for states implementing the community engagement requirements.
▸ Ballooning Deficit Despite Massive Cuts: CBO and the staff of the Joint Committee on Taxation estimate that enacting the bill would increase deficits over the 2025–2034 period by $2.4 trillion, excluding any macroeconomic or debt‑service effects. That change stems from a reduction in revenues of $3.7 trillion and a reduction in outlays of $1.3 trillion over the 2025–2034 period. CBO estimates that the additional debt-service costs under the bill would total $551 billion over the 10-year period. CBO estimates that debt-service costs under H.R. 1, the One Big Beautiful Bill Act, would total $551 billion over the 2025–2034 period—increasing the bill's cumulative effect on the deficit to $3.0 trillion.
▸ Administrative Burden Falls on States Facing Funding Cuts: Many of these, including work requirements and more frequent eligibility redeterminations, will create greater administrative burden and costs for states, just as they are facing federal funding cuts. States must verify work compliance, send notifications, and hear appeals—all without proportional federal funding. Rural states face particular strain.
▸ $5 Trillion Debt Ceiling Increase with No Corresponding Deficit Reduction: H.R. 1, the 2025 reconciliation legislation signed by the President on July 4, 2025, increased the debt limit by $5 trillion. This is not a procedural matter—it means Congress authorized $5 trillion in additional borrowing, yet the bill itself only offsets a tiny fraction of its cost through spending cuts.
▸ Sunset of Tax Benefits Creates Hidden Time Bombs: Another concern is the temporary nature of many of the bill's benefits. Several tax breaks and credits are set to phase out after 2028, which critics say undermines the bill's long-term stability and creates uncertainty for families and businesses planning for the future. This sunset clause raises questions about whether the bill is a sustainable solution or a short-term political maneuver.
▸ Medicaid Eligibility Rule Rescission Targets Seniors and Disabled: CBO has previously estimated that by itself, rescinding the rule would cut Medicaid enrollment by 2.3 million people in 2034. Based on CMS' regulatory impact analysis, most of those losing Medicaid coverage would likely be seniors and people with disabilities also enrolled in Medicare. Earlier preliminary CBO estimates indicate that 1.3 million people who are dually eligible for Medicare and Medicaid would lose their Medicaid coverage under the bill.
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Who benefits
• High-Income Earners and Wealth Holders: The Child Tax Credit is made permanent. The credit increases to $2,200, subject to a phaseout. The phaseout begins at an income of $200,000 for single filers and $400,000 for joint filers. The Joint Committee on Taxation estimates that Senate Republicans' proposal will cost $4.45 trillion, but despite the price tag, the legislation primarily helps billionaires at the expense of American working families. In fact, this legislation would provide a huge, permanent tax cut of nearly $350,000 for multimillionaires and billionaires while people earning $40,000 a year will see a comparatively meager average tax decrease of $442 per year.
• Corporations and Business Owners: The section 179 expensing provision cap is now $2.5 million, indexed for inflation. The 100% bonus depreciation provisions of the TCJA are now permanent. The Qualified Opportunity Zone (QOZ) program is now permanent with some modifications.
• Defense Contractors and Border Security Companies: The package also included boosts to border funding, extended tax cuts and made policy changes to immigration, energy and defense.
• Married Couples and Parents with Children: The child tax credit allows eligible taxpayers to reduce their federal income tax liability by up to $2,200 per qualifying child (indexed to inflation). If their tax liability is less than the value of their child tax credit, they may be eligible for a refundable credit calculated using the earned income formula. This benefits middle-income families with children, though the full benefit phase-out at $400,000 for married couples.
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Who gets hurt
• Medicaid Recipients Aged 19-64 in Expansion States: H.R. 1 mandates that Medicaid members aged 19-64 who are covered through the Affordable Care Act Medicaid expansion or an 1115 demonstration waiver that provides minimum essential coverage must engage in employment, education, a work program, or community service to maintain their Medicaid eligibility. Millions of working-poor adults—including those with disabilities, caregivers, and underemployed workers—face coverage loss if they cannot document 80 hours/month of work.
• Rural Healthcare Providers and Communities: In northeast Georgia, a hospital closed its maternity ward. In rural New Hampshire, a community health center shuttered. And in Iowa, a Des Moines hospital system laid off dozens of employees and closed a clinic. Rural health providers that rely on Medicaid funding were already under strain before the bill cut federal health spending by hundreds of billions of dollars over the next decade. Rural communities may face increased health risks as deep Medicaid cuts strain the finances of rural hospitals, while the bill's $50 billion health fund covers only a fraction of the expected shortfall.
• Children and Pregnant Women: Child enrollment in Medicaid and CHIP grew from 35.2 million in February 2020 to a high of 42.3 million during the COVID-era enrollment protections but dropped to 37.3 million by April 2025. Enrollment declines for children are expected to continue for a variety of reasons, and pressure on state eligibility systems will make it slower and harder for eligible children to regain Medicaid coverage.
• Immigrants: The legislation includes an estimated $863 billion in budget cuts for Medicaid and $295 billion in cuts for the Supplemental Nutrition Assistance Program (SNAP) for fiscal years 2025 to 2034. The law strips coverage from many lawfully residing immigrants.
• SNAP Recipients: The legislation includes an estimated $863 billion in budget cuts for Medicaid and $295 billion in cuts for the Supplemental Nutrition Assistance Program (SNAP) for fiscal years 2025 to 2034. The combined cuts exceed $1 trillion.
• Marketplace Health Insurance Buyers: Unless Congress extends those subsidies before December 2025, Marketplace enrollees will face steep premium hikes with CBO estimating that 4.2 million will become uninsured.
• Low-Income Workers (General Tax Impact): While the bill cuts income taxes for most earners, there is also some confusion on the impact of the bill on the amount most people would pay in taxes. The House version of the bill is expected to cut taxes for most Americans, but four in ten (38%) think it would increase taxes, 21% correctly say it would decrease taxes, and about four in ten saying the tax rate would either not be changed (15%) or they are not sure (25%).
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What it does
This act reduces taxes, reduces or increases spending for various federal programs, increases the statutory debt limit, and otherwise addresses agencies and programs throughout the federal government. The bill operates on two levels: tax changes and healthcare/spending changes. On taxes, the TCJA personal income tax rates and brackets are now permanent. The seven (7) brackets are 10%, 12%, 22%, 24%, 32%, 35%, and 37%. The temporary TCJA standard deduction amounts ($15,750 for individual filers, $31,500 for joint filers, and $23,625 for heads of households) are made permanent. The Child Tax Credit is made permanent. The credit increases to $2,200, subject to a phaseout. The 100% bonus depreciation provisions of the TCJA are now permanent. The Qualified Opportunity Zone (QOZ) program is now permanent with some modifications.
On healthcare, the bill reshapes Medicaid dramatically. One source of the law's Medicaid cuts is a 10-year moratorium on implementation or enforcement of provisions in two rules finalized by the Biden administration that would have reduced administrative burdens to make it easier for people to enroll in and maintain Medicaid and CHIP coverage. In effect, the law delays or pauses implementation of many provisions in the two rules until October 2034. Congress enacted cuts of approximately $1.15 trillion on federal health care spending over the next decade. The final version of the bill included further constraints on state Medicaid financing and eligibility and significantly scaled back Marketplace subsidies for certain populations. The work requirement mandate (Section 71119) becomes effective January 1, 2027, requiring states to verify work participation of 80 hours per month for non-exempt adults 19-64. H.R. 1, the 2025 reconciliation legislation signed by the President on July 4, 2025, increased the debt limit by $5 trillion.
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Hidden riders
- Regulatory Bypass for Medicaid Work Requirements: H.R. 1 requires the Secretary to promulgate an interim final rule for purposes of implementing the community engagement policy no later than June 1, 2026. This rule and any subsequent amendments are explicitly exempt from formal notice and comment rulemaking outlined at 5 U.S. Code § 553. This means HHS can implement the rule without the normal public comment period, eliminating accountability for how the rule is written.
- Medicare GLP-1 Bridge Program: The Medicare GLP-1 Bridge program will start on July 1, 2026. Through this short-term demonstration, CMS will be expanding access to certain GLP-1 medications to eligible Medicare Part D beneficiaries who do not currently have access to these medications through the Part D benefit. This was buried in the bill as a temporary program but creates political cover for addressing weight-loss drug access debates.
- State Plan Amendment Authority for Work Requirements: These requirements cannot be waived under Section 1115, though states may request "good faith" exemptions through 2028. This strips away traditional waiver authority, forcing compliance even if states identify harms to vulnerable populations.
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Precedent
The bill's precedent is mixed. The enactment of H.R.1 establishes mandatory work reporting requirements for certain Medicaid enrollees, marking the first federal mandate making Medicaid eligibility conditional on work or other qualifying activities in the program's history. This is historically unprecedented—previous work requirements required state waivers and were often challenged or reversed (as happened under the Biden administration). On the tax side, the bill mirrors 2017 when the Trump administration passed the Tax Cuts and Jobs Act as a temporary measure. This bill makes that temporary law permanent—essentially doubling down on a strategy that increased deficits substantially. The 2017 TCJA added roughly $1.5 trillion to deficits over a decade; making it permanent adds another $2.6 trillion by some estimates. The reconciliation process itself (used here to pass the bill with 51 Senate votes instead of 60) has been deployed by both parties for major fiscal legislation since 1990, but the scale of this bill—combining massive tax cuts with healthcare restructuring—represents an unusually broad use of the mechanism.
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Current status
On May 22, 2025, the U.S. House of Representatives passed H.R 1, the One Big Beautiful Bill Act, by a vote of 215-214. The Senate on July 1 voted 51 to 50 to pass an amended version of H.R. 1, the "One Big Beautiful Bill Act." The bill was approved with the tie-breaking vote of Vice President JD Vance and the support of all Senate Republicans, except for Senators Susan Collins (R-ME), Rand Paul (R-KY), and Thom Tillis (R-NC) who opposed the bill along with all Senate Democrats. President Donald J. Trump on July 4 signed into law H.R. 1, the "One Big Beautiful Bill Act." The bill was passed by the House on July 3 by vote of 218 to 214. The bill is now law. The next major event is June 1, 2026, when CMS must issue the interim final rule on Medicaid work requirements. States will then scramble to build implementation systems for a January 1, 2027 deadline. Legal challenges will likely begin in fall 2025 or early 2026. The healthcare provisions will begin affecting enrollment in late 2026 when state systems go live with new eligibility rules.
What to watch
States are required to implement work requirements by January 1, 2027, though they may choose to do so sooner through 1115 waivers. The final legislation permits the Secretary to grant extensions until December 31, 2028 for states that can demonstrate a good faith effort to meet the requirements. Watch for: (1) How many states seek "good faith" exemptions and whether HHS grants them; (2) Litigation challenging work requirements as arbitrary or unconstitutional (likely from disability rights groups and NAACP); (3) Whether marketplace premium subsidies expire in December 2025, triggering another emergency legislative push; (4) State responses—some will implement narrowly to minimize coverage loss, others aggressively; (5) 2026 election messaging using hospital closures and coverage loss as campaign issues, particularly in swing districts. In Georgia promoting the "One Big Beautiful Bill Act" last August, Vice President JD Vance slammed Ossoff's opposition to the legislation, saying he was "allegedly worried about people getting kicked off their health care." "Well, you know what? The President of the United States made a promise, a sacred promise that the only people who are going to lose access to health care are illegal aliens who shouldn't be in this country to begin with," Vance said. This suggests the administration will face intense pressure to show those cutting Medicaid are primarily affecting immigrants—a claim contradicted by CBO projections.
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