Congress passed and President Trump signed into law the reconciliation bill, which includes changes to Medicaid and the ACA that will result in deep coverage losses.

Since the last update…

The Senate passed its version of the bill last Tuesday.

• The vote was 51-50, with Vice President Vance breaking a tie. Sens. Collins, Paul, and Tillis joined Democrats in voting no.
• The vote followed nearly a full day of round-the-clock uncertainty over how the bill would come together, following a slow-moving vote-a-rama that lasted overnight as leaders tried to win over holdouts.
• Before passage, the Senate boosted the amount of money in the bill for the rural hospital fund to $50 billion over 5 years and included $20 million for HHS to implement the provider tax changes (up from $6 million).

The Senate sent the bill back to the House, which originally passed the bill in May but had to vote again after the Senate made changes.

• Some House members were worried about changes the Senate made to Medicaid provisions, while others felt the Senate spending cuts were insufficient and that the bill added too much to the deficit. Some called for changes to the Senate bill before voting, but that would have delayed the bill beyond the self-imposed July 4 deadline.

The House passed the Senate bill Thursday, following overnight procedural votes Wednesday that were delayed hours as House leaders worked to win over holdouts.

• One preliminary vote was held open for more than 9 hours, and a second took 6 hours. But leaders secured the votes, after pressure and discussions on spending cuts the administration could make via executive action and how providers would be able to access the rural hospital fund. Early Thursday morning (around 3:30 a.m.), the House cleared the procedural hurdle in a 219-213 vote that set up the final floor vote. Rep. Fitzpatrick joined all Democrats in voting against the rule for floor consideration of the bill.
• House Minority Leader Jeffries delayed final action almost another 9 hours with a record-breaking speech attacking the bill.
• The final vote Thursday afternoon was 218-214, with Republican Reps. Fitzpatrick and Massie joining Democrats in opposition.

Trump signed the bill into law Friday during the White House Fourth of July picnic.

What’s coming:

• The effects of many of the health care cuts will not be felt for several years. Medicaid work requirements generally won’t kick in until 2027, and some states could get extensions. Increased Medicaid eligibility checks will start Dec. 31, 2026, and the phasedown of Medicaid provider taxes and state-directed payments in 2028.
• But: People covered through ACA exchanges could see changes more quickly, with enhanced premium subsidies set to expire at the end of the year. Restrictions on immigrants’ access to Medicaid will go into effect Oct. 1, 2026. Hospitals and clinics are already making contingencies for the Medicaid cuts and coverage losses, which could translate into facility closures or elimination of services.
• Advocates will likely press Congress to further delay the provisions or stop them from taking effect.

What’s in the bill: The bill contents did not change much since our last update on the Senate version, but here is a reminder on just a few of the biggest changes.

• The law cuts federal health spending by over $1.1 trillion, with over $1 trillion cuts to Medicaid alone (according to the latest estimates on an earlier Senate version of the bill, though the final is not expected to be hugely different). It could lead to nearly 12 million more people without insurance by 2034.
• Medicaid work requirements: The deepest cuts to health care spending come from new Medicaid work reporting requirements for adults 19-64 who do not have young kids and who are eligible for Medicaid via the ACA’s expansion. While there would be exceptions, including for those with chronic SUD, they would be too limited and burdensome to prevent coverage losses.
• Medicaid eligibility: The law will require more frequent eligibility checks in Medicaid (at least twice a year vs. once a year) and undoes Biden-era rules that streamlined Medicaid enrollment and eligibility.
• Medicaid funding: The law curtails provider taxes, a key way states pay for their share of Medicaid costs, and state-directed payments, which states use to pay some Medicaid providers at higher rates. These changes could lead states to provide fewer health or other services and could lead to health care providers closing. The bill includes a rural health fund of $50 billion over 5 years to address this, but it is insufficient to address the scope of the cuts.
• ACA coverage: The law would make it harder to enroll in and retain coverage through ACA marketplace plans. The law would end automatic reenrollment, requiring individuals to re-sign up and provide information every year. It also shortens the annual enrollment period, and people will have to wait for their application to be processed before receiving premium subsidies (vs. getting 90 days of premium help during the application process). It limits who is eligible for premium tax credits, including ending access for some legal immigrants.