In July 2025, President Trump signed the One Big Beautiful Bill Act into law. The legislation is a large budget reconciliation bill that mainly focuses on tax cuts and reduced social spending. One social program facing a substantial reduction in spending due to the bill is Medicaid, the largest single insurer in the United States.
There is a laundry list of changes coming to Medicaid in the next few years, but the ones affecting beneficiaries the most are new work requirements for Medicaid expansion coverage and more frequent eligibility checks.
New work requirements for Medicaid
By 2027, states must mandate that recipients engage in at least 80 hours per month of paid employment, job training, education, or community service to remain eligible for Medicaid coverage. Exceptions to this rule include parents with children ages 13 and younger and those who are medically frail.
Currently, states are generally prohibited from making Medicaid eligibility contingent on work. During the first Trump presidency, 13 states received approval to implement work requirements through Section 1115 waivers, which allow states to experiment with Medicaid models that differ from federal statutes. All 13 of these states either had these waivers rescinded during the Biden presidency or withdrew them voluntarily. As of now, Georgia is the only state that maintains work requirements, also through a Section 1115 waiver.
Work requirements for Medicaid coverage are likely to result in fewer covered individuals due to procedural barriers such as submitting documentation to prove they have met the hourly quotas. This may disproportionately impact nontraditional workers such as those who rely on gig work. Recipients who meet an exception, such as those who are chronically ill, may also find it more challenging to navigate complex online portals or submit specific medical documentation.
More frequent eligibility checks for Medicaid
The One Big Beautiful Bill Act also requires states to check for eligibility for Medicaid more frequently. By 2028, states must verify whether Medicaid enrollees are still eligible for services at least every six months, with flexibility provided to states to check more often if they choose. Currently, states are only required to confirm Medicaid eligibility annually.
More frequent eligibility checks are expected to reduce Medicaid coverage due to procedural barriers such as address changes, missing notifications, and increased opportunities for administrative errors. It is also likely that more recipients will become temporarily disenrolled and then reenrolled, which only serves to increase the administrative burden for state and local governments.
Medicaid enrollment reductions due to the One Big Beautiful Bill Act
In total, between 4.9 and 10.1 million people will lose Medicaid coverage in 2028 due to work requirements and more frequent eligibility checks. Roughly 2 to 3.1 million of these recipients will lose coverage due to their eligibility being redetermined more frequently, and roughly 3 to 7 million will lose coverage specifically due to work requirements.
Because Medicaid is administered primarily at the state level, the impacts of these proposed changes will ripple through the states, with the individual effects varying widely by region. In the following table, we show the number of disenrollments expected from each state in 2028 based on analysis from the Robert Wood Johnson Foundation, ordered from highest to lowest percent change.
| Medicaid Enrollment Reductions | ||
| State | Projected Coverage Loss | Percent Change |
|---|---|---|
| Massachusetts | −161,000 | −54% |
| Connecticut | −155,000 | −51% |
| Maryland | −172,000 | −51% |
| Vermont | −20,000 | −50% |
| Minnesota | −91,000 | −49% |
| New York | −955,000 | −48% |
| Virginia | −269,000 | −47% |
| Missouri | −169,000 | −47% |
| California | −1,995,000 | −46% |
| Delaware | −28,000 | −45% |
| New Jersey | −242,000 | −44% |
| Arizona | −197,000 | −44% |
| New Hampshire | −23,000 | −44% |
| Illinois | −324,000 | −44% |
| Rhode Island | −34,000 | −43% |
| Colorado | −165,000 | −43% |
| Hawaii | −57,000 | −43% |
| Washington | −260,000 | −43% |
| West Virginia | −61,000 | −42% |
| Wisconsin | −70,000 | −42% |
| Maine | −28,000 | −41% |
| Kentucky | −166,000 | −41% |
| Louisiana | −205,000 | −41% |
| District of Columbia | −46,000 | −41% |
| Ohio | −285,000 | −40% |
| Iowa | −72,000 | −40% |
| Michigan | −287,000 | −40% |
| Utah | −33,000 | −40% |
| Idaho | −30,000 | −38% |
| Nevada | −113,000 | −38% |
| Pennsylvania | −276,000 | −37% |
| Oklahoma | −87,000 | −37% |
| Montana | −28,000 | −36% |
| Arkansas | −78,000 | −36% |
| North Carolina | −249,000 | −36% |
| Alaska | −23,000 | −36% |
| New Mexico | −87,000 | −36% |
| Nebraska | −25,000 | −35% |
| Indiana | −201,000 | −35% |
| Oregon | −185,000 | −34% |
| South Dakota | −11,000 | −34% |
| North Dakota | −8,000 | −30% |
Many of the states with the highest Medicaid enrollment rates are the states projected to be most affected by changes to Medicaid from the One Big Beautiful Bill Act, such as Massachusetts and Connecticut. Generally, states are expected to lose between 30% to 54% of their expansion populations due to eligibility changes.
How the One Big Beautiful Bill Act will change uninsured rates
While Medicaid is frequently considered a program intended solely to improve health outcomes, it effectively serves as a mechanism for fiscal relief for millions of American households. By ensuring access to low-cost health insurance, Medicaid frees up household budgets, providing recipients with more disposable income for necessities like housing and food, while reducing the likelihood of falling into medical debt. When people lose Medicaid coverage, especially lower-income populations, they face a tradeoff: pay out-of-pocket premiums for a private health insurance plan or forego coverage to save money for other immediate expenses.
To understand how changes to Medicaid from the One Big Beautiful Bill Act will affect uninsured populations, we compare current uninsured numbers to the potential increases expected from Medicaid recipients losing eligibility in 2028.
| Impact on Uninsured Populations | ||||
| State | Projected Coverage Loss | Current Uninsured | Projected Total Uninsured | Percent Change |
|---|---|---|---|---|
| New York | −955,000 | 973,715 | 1,928,715 | 98% |
| California | −1,995,000 | 2,314,464 | 4,309,464 | 86% |
| Oregon | −185,000 | 219,386 | 404,386 | 84% |
| Massachusetts | −161,000 | 198,589 | 359,589 | 81% |
| Connecticut | −155,000 | 211,726 | 366,726 | 73% |
| West Virginia | −61,000 | 100,543 | 161,543 | 61% |
| Louisiana | −205,000 | 348,045 | 553,045 | 59% |
| Michigan | −287,000 | 507,760 | 794,760 | 57% |
| Kentucky | −166,000 | 308,763 | 474,763 | 54% |
| Washington | −260,000 | 511,691 | 771,691 | 51% |
| Virginia | −269,000 | 595,595 | 864,595 | 45% |
| Maryland | −172,000 | 390,741 | 562,741 | 44% |
| Iowa | −72,000 | 174,113 | 246,113 | 41% |
| New Mexico | −87,000 | 211,289 | 298,289 | 41% |
| Indiana | −201,000 | 512,807 | 713,807 | 39% |
| Delaware | −28,000 | 71,608 | 99,608 | 39% |
| Illinois | −324,000 | 860,898 | 1,184,898 | 38% |
| Pennsylvania | −276,000 | 752,566 | 1,028,566 | 37% |
| Maine | −28,000 | 76,864 | 104,864 | 36% |
| Ohio | −285,000 | 782,626 | 1,067,626 | 36% |
| Missouri | −169,000 | 474,886 | 643,886 | 36% |
| Colorado | −165,000 | 463,722 | 628,722 | 36% |
| New Jersey | −242,000 | 727,278 | 969,278 | 33% |
| Minnesota | −91,000 | 290,828 | 381,828 | 31% |
| Nevada | −113,000 | 366,606 | 479,606 | 31% |
| Alaska | −23,000 | 77,532 | 100,532 | 30% |
| Montana | −28,000 | 98,102 | 126,102 | 29% |
| Arkansas | −78,000 | 284,915 | 362,915 | 27% |
| North Carolina | −249,000 | 927,893 | 1,176,893 | 27% |
| Arizona | −197,000 | 767,380 | 964,380 | 26% |
| Wisconsin | −70,000 | 310,536 | 380,536 | 23% |
| Oklahoma | −87,000 | 461,884 | 548,884 | 19% |
| Nebraska | −25,000 | 139,831 | 164,831 | 18% |
| Idaho | −30,000 | 181,552 | 211,552 | 17% |
| South Dakota | −11,000 | 73,403 | 84,403 | 15% |
| Utah | −33,000 | 288,681 | 321,681 | 11% |
We project some of the most populated states to see the highest percent increases in the number of uninsured residents. We project New York, for instance, to see its uninsured population surge by over 98%, effectively doubling the number of uninsured residents. Similarly, California and Oregon face increases of 86% and 84% respectively, penalizing states with high populations and high Medicaid enrollment.
If those who lose Medicaid coverage remain uninsured, health systems in low-income communities which rely on Medicaid funds may become strained, worsening accessibility to medical facilities for low-income communities even more.
The Long-Term Outlook
The changes coming to Medicaid in the One Big Beautiful Bill Act will likely lead to millions of people losing coverage across the country. This change represents a shift in the priorities of Medicaid spending from promoting health insurance coverage for low-income households to reducing state and federal spending on Medicaid line items. While these changes may save taxpayers in the short run, they risk straining the administrative capacities of state and local governments and worsening healthcare options for low-income households across the nation.
