Passage of H.R. 1, the One Big Beautiful Bill Act (OBBBA) is a public health watershed. In the modern history of U.S. social welfare policy, no single law has done more to strip vital health, nutrition, and economic resources away from the poorest and most vulnerable children and adults, with profound ramifications for the entire U.S. population. Regardless of income, Americans rely on the same hospitals and the same health care providers. For this reason, it is impossible to take away health insurance coverage from 17 million people, according to CBO estimates, without the population having to pay a heavy price.
H.R. 1’s health and health care consequences will be felt nationwide for years to come. Certain effects will be evident almost immediately; the impact of other provisions will take longer to fully emerge. In the coming months and years, states, localities, health care providers, and public health institutions will be forced to grapple with the massive and profoundly consequential task of adjusting essential programs and services to the new realities the legislation will force Americans to confront.
Evidence of harm
Over decades, public health researchers have documented the effects of being uninsured and the significant positive impact on health care access and health of gaining insurance. Debate and passage of HR 1 unfolded against this background. Over the months that H.R. 1 has been debated, significant research on its likely effects has emerged. Taken together, a large body of evidence has projected the likely effects of the legislation, whose health care provisions have been designed to remove millions of people from Medicaid and the system of tax subsidies that put ACA coverage within reach. This evidence has documented the likely effects on coverage, as well as the implications of coverage losses for health care access.
Examples from the emerging literature
- Detailed estimates show the combined effects of H.R. 1 on insurance coverage and how its Medicaid and ACA marketplace changes will combine to dramatically expand the uninsured rate.
- Estimates go beyond the nationwide, and demonstrate on a state-by-state basis how H.R. 1 will affect residents in every state.
- Estimates show how the changes will affect health care spending and the burden of uncompensated care – more than $1 trillion lost to the health care system and a $200 billion rise in uncompensated care.
- The accessibility and stability of primary health care in medically underserved rural and urban communities will be deeply affected, with coverage losses among patients served by community health centers expected to surpass 9 million.
- No population will be left untouched. Low income working age adults who for the first time gained access to health insurance as a result of the Affordable Care Act, have been the measure’s direct targets. But, as past experience has demonstrated, when states face enormous difficulties raising the revenue needed to operate their Medicaid programs – another specific aim of H.R. 1 – no population is spared, including older adults and people with disabilities.
- Over time, deep Medicaid spending reductions will affect populations who have not been directly targeted. This includes millions of low-income children and pregnant women whose incomes are just above the federal poverty level and whose coverage is optional.
- Low-income working age adults, who gained coverage under the Affordable Care Act are the most heavily exposed under the legislation. The impact of the changes will fall most heavily not on young healthy adults who naturally leave Medicaid as they enter the workforce, but instead on older sicker adults no longer able to hold steady jobs. Four in five people whose coverage is at risk as a result of the barriers that will stand between them and coverage are deeply impoverished women, with an average age of 41; one in 4 is over age 50. Community health centers, the primary health care system that serves nearly 32 million rural and urban residents of medically underserved communities, are projected to see over 5 million patients lose Medicaid, with financial losses exceeding $30 billion.
- Ultimately the effects of coverage losses extend far beyond specific populations, given the significance of the health care economy to the overall economy.
- Beyond affecting coverage for millions, loss of more generous ACA tax subsidies at the end of 2025 can be expected to result in job loss by almost 300,000 people, about half of whom are health care workers. These losses will be felt most severely in Medicaid nonexpansion states, whose residents are especially reliant on the marketplace. Overall, state economies can be expected to contract by $34 billion as a result of the loss of marketplace subsidies.
- Medicaid work requirements will exact a major economic cost as a result of widespread coverage losses among people unable to navigate the paperwork process. Projected economic losses among states could exceed $500 billion over the coming decade, along with hundreds of thousands of jobs tied to the health care economy.
- In combination with the deep reductions in assistance through the Supplemental Nutrition Assistance Program (SNAP), the economic consequences in health care and food assistance could cause 1.2 million jobs to be lost, equivalent to a 0.8 percentage point increase in the unemployment rate. About half the jobs lost would likely be in health care; hospitals, clinics and other health facilities would experience serious losses and some would close. In 2029, state economies would be $154 billion lower. State and local tax revenues would fall by $12 billion, making it harder for them to compensate for the loss of federal funding and making it harder to cover costs for education and other important services. The version of OBBBA passed by the Senate is broadly similar, with deeper cuts in Medicaid, but somewhat smaller cuts in SNAP funding.
Going forward
Some of H.R. 1’s health care effects will be visible in the near term. Many more will come with time, and the importance of documenting these effects will be a public health priority.
Dean Lynn Goldman wants to express gratitude to the health policy scholars who helped author this statement: Sara Rosenbaum, Professor Emerita of Health Law and Policy, Leighton Ku, Director of the Center for Health Policy Research, Alison Barkoff, the Hirsh Health Law & Policy Associate Professor and Feygele Jacobs, Professor of Health Policy and Management—all at the GW Milken Institute School of Public Health.
Lynn Goldman serves as the Dean of the GW Milken Institute School of Public Health.
This statement reflects the views of the authors and does not reflect that of the institution.