The massive tax cut legislation passed by the House and Senate this week will dramatically upend health care in America.

The legislation, now on its way to President Trump, was never framed as a health bill, but it will mark the biggest changes to U.S. health policy since the Affordable Care Act (ACA) was passed in 2010. 

The bill’s provisions will impact patients, doctors, hospitals, and insurers, as Republicans partially paid for it by cutting more than $1 trillion from federal health programs. 

The bulk of the cuts are coming from Medicaid. As a result, changes are coming that will affect how people qualify for and enroll in the program that covers more than 70 million low-income and disabled Americans, as well as how they can maintain coverage.  

“No matter how often repeated, the magnitude of these reductions and the number of individuals who will lose health coverage cannot be simply dismissed as waste, fraud, and abuse,” American Hospital Association president Rick Pollack said in a statement. 

“The faces of Medicaid include our children, our disabled, our seniors, our veterans, our neighbors, and friends. The real-life consequences of these reductions will negatively impact access to care for all Americans.” 

Almost 12 million lower-income Americans would lose their health insurance by 2034, according to the Congressional Budget Office (CBO), blunting the significant coverage gains made under the ACA.  

The cuts were deep enough to give some Republicans in both chambers pause, but in the end, only two GOP House members and three senators voted against the bill. It passed the Senate 51-50, and the House 218-214. 

Here’s how the bill could impact Americans: 

Medicaid 

By design, the group that would be hit the hardest are people whose income is between 100 percent and 138 percent of the federal poverty level (roughly between $32,150 and $42,760 for a family of four) who gained insurance when their states expanded Medicaid. 

The most significant change will be a first-ever requirement for adults under age 65 including low-income parents of children older than 14 to prove they work, volunteer or go to school at least 80 hours a month. States will need to develop and launch systems to verify individuals’ work status at least every six months, beginning in December 2026. 

Health experts and advocates warn that a blizzard of red tape and administrative hurdles will strip people of needed health care, even those who would normally be eligible. 

GOP lawmakers say they are fine with those consequences, even those who have said they oppose cutting Medicaid benefits, because the requirements will only target the “able-bodied” people who should be working but choose not to.   

Groups such as the disabled, pregnant women and people who are in prison or rehabilitation centers would be exempt from the requirements. Those people, Republicans say, are the truly needy.   

But someone who qualifies would need to prove they are exempt, which would require submitting the correct forms and documentation in the correct order at the time they apply for Medicaid and after they are already enrolled.

Outside of work requirements, the legislation requires states to do an extra eligibility check on Medicaid enrollees starting in 2027. Checking every six months opens the possibility of a person losing coverage mid-year. 

The bill will also require people with incomes above the poverty line to pay out-of-pocket copays for most Medicaid services, like lab tests or doctor visits. States will be allowed to charge up to 5 percent of a person’s income per year, though some Democratic-led states may opt for a smaller amount.  

Primary care, mental health and substance abuse services are exempted, and prescription drugs would only have a nominal copay. 

The bill could also limit the number of clinics available to patients who need abortions, even in states where it’s legal. It targets Planned Parenthood without explicitly mentioning the organization by banning federal Medicaid funds from going to clinics that offer abortions. 

Nearly 200 Planned Parenthood health centers in 24 states across the country are at risk of closure, the organization said. More than 90 percent of those closures would occur in states where abortion is legal.  

ObamaCare exchanges 

The legislation will make it more difficult for people to sign up for and afford health plans on ACA exchanges. 

It will limit eligibility for premium subsidies to people living in the U.S. who are not eligible for any other federal insurance program. It will also bar most immigrants and lawful permanent residents from receiving the subsidies.  

The bill will require real-time verification of eligibility before a person can receive those subsidies to help afford premiums.  

Currently, anyone who purchases a subsidized plan can begin using it almost immediately. The state or federal government has 90 days to determine eligibility. But under the new bill, people won’t have access to cheaper premiums until they are deemed eligible. 

In addition, people who sign up for ACA coverage during some special enrollment periods will not be eligible for subsidies. 

The bill will also end automatic reenrollment ahead of the 2028 sign-up period, meaning enrollees will need to update their income, immigration status and other information each year. 

According to health research group KFF, 10 million people were automatically reenrolled in ACA plans in 2025.  

Rural and safety-net hospitals 

The GOP bill could pose a major problem for rural hospitals, and subsequently the patients who rely on them. 

Changes to state-levied provider taxes would reduce spending by nearly $191 billion over a decade, according to the CBO estimate. An analysis of an earlier version introduced in the Senate by the National Rural Health Association and Manatt Health found the legislation generates $58 billion in Medicaid cuts over the next ten years for rural hospitals. 

The bill that passed includes a five-year, $50 billion rural health relief fund, but provider groups say it’s a band-aid compared to the overall cost of the cuts. 

Hospitals would see a spike in uncompensated care and overcrowding of emergency rooms. 

“Millions of Americans will see their health care coverage vanish through burdensome Medicaid work requirements and other eligibility changes throughout the bill. Hospitals across the country have been destabilized, affecting their ability to serve patients and their communities. We are in a crisis,” said Bruce Siegel, president and CEO of America’s Essential Hospitals, a group that represents hospitals serving primarily low-income patients.  

“Widespread coverage losses plus weakened hospitals is a recipe for disaster, and patients will pay the price.”