Over the past decade, the United States has made meaningful progress in expanding health coverage and improving care for millions of Americans. But that progress is now in jeopardy. The newly passed “One Big Beautiful Bill Act’’ will have far-reaching consequences for the health insurance of millions of Americans. The Congressional Budget Office estimates that nearly 10 million Americans could lose their health insurance by 2034 as a result of the new legislation. In Massachusetts, officials estimate 300,000 people are at risk of losing their health coverage.
In most instances this won’t be because people aren’t eligible. It will be because of bureaucratic red tape. The legislation creates new administrative burdens and reporting hurdles that make it harder for people to get or keep coverage, even when they’re fully eligible. This includes work verification requirements for people on Medicaid, tightened eligibility rules, and new restrictions on coverage for immigrants.
These changes will worsen health outcomes for people who lose coverage while leading to higher costs for both patients and hospitals. It will overburden nursing homes, community health centers, and emergency departments, and some facilities may be forced to reduce services, lay off staff, or close altogether.
How bad will the damage be? Well, a lot depends on how states respond. By streamlining enrollment systems, investing in community partnerships, and making targeted investments to protect at-risk populations, states can soften the worst effects of this bill, reduce how many eligible people lose coverage, and ultimately ensure millions of people still get the care they need.
Simplify enrollment so more people can keep their coverage
First, states must make it as easy as possible for eligible people to stay covered. States can do this by simplifying their enrollment systems. That starts with expanding automatic verification and leveraging electronic records, like tax data and Social Security information, to confirm eligibility and income status automatically. These steps will reduce paperwork, minimize errors, and ensure that people don’t lose coverage because of a missed deadline or procedural mistakes. Massachusetts, for example, is already making plans to address these administrative hurdles, and other states should follow suit.
One area that needs particular attention is Medicaid work requirements. They are currently used in a few states, and the new bill expands this policy nationwide despite plenty of evidence that it leads to significant coverage losses, including among adults who are already working.
When Arkansas implemented such requirements in 2018, more than 18,000 people lost coverage in just a few months. The vast majority of those losses weren’t driven by refusal to work, but by confusion and administrative barriers. Enrollees — many of whom were working or qualified for exemptions — were required to report their work hours monthly through online portals, paper forms, or phone calls. The process led to thousands of enrollees falling through the cracks. It is also incredibly expensive. In Arkansas, it cost the state $26 million to run.
To avoid repeating that failure, state legislators should explore adopting broad exemptions for caregivers, students, and individuals with disabilities unable to meet requirements. Reporting systems should be easy to access, mobile and online friendly, and supported by staffed help lines. States can also invest in voluntary job training and community service programs that assist people both in meeting work requirements and gaining valuable skills. Steps like these can reduce coverage losses, offer real support, and strengthen communities.
States with their own ACA marketplaces should extend open enrollment periods beyond the shorter federal window, giving families more time to understand their options and enroll. Small changes like this can make a big difference, especially for people with limited internet access or nontraditional work hours.
Tap community resources to help people navigate the complexities of health care coverage
Next, states should better engage local communities, their leaders, and their trusted institutions. Local health providers, advocacy groups, and faith-based organizations can educate people about their rights and offer assistance in navigating the entire enrollment process. In California, the state’s health insurance program worked with local libraries to run simple workshops in different languages that helped people understand their health insurance options and sign up for coverage.
Information sessions at community centers, multilingual assistance, and text message reminders are valuable tools in helping the most vulnerable populations, including legal immigrants who are eligible to meet documentation requirements and avoid unnecessary coverage loss, especially out of fear or confusion. It’s part of why health care providers, who stand to lose substantial amounts of money in reimbursements, should lead outreach efforts to ensure that people who are eligible for Medicaid get or keep their insurance.
Use targeted investments to strengthen the safety net
Finally, targeted investments by states can minimize the impact of health coverage loss. Wholesale replacement of lost federal funds won’t be possible. Massachusetts, for example, has used an uncompensated care fund known as the Health Safety Net to support hospitals serving the uninsured, but that fund has become critically strained and far less capable of meeting growing demand. States should create or, in Massachusetts’s case, bolster and expand similar safety nets to ensure the most vulnerable don’t lose access to essential health services.
States should also consider expanding cost-sharing reductions to lower deductibles and out-of-pocket costs for low-income residents who might otherwise forgo care. Reinsurance programs are another proven tool, and states like Washington and Minnesota have shown how these programs can stabilize marketplaces and keep coverage affordable.
At the end of the day, the greatest threat to sustainable health coverage in America isn’t paperwork, policy, or a new bill — it is cost. Health care in the United States remains extraordinarily expensive, and the new federal bill does nothing to address it. States could do more to address the root of the problem, including exceedingly high prices and lack of competition among health care providers. Too few states have put much attention on these fundamental issues.
The bill is now law, but as with any law, implementation will play a critical role in its impact. States have a lot of leverage and leeway in ensuring that it is implemented in ways that minimize coverage loss, through simplifying hurdles, outreach to communities, and targeted investments that can make a difference. If states do their job right, we can substantially reduce the number of eligible Americans who will find themselves without coverage.