The passage of the One Big Beautiful Bill (OBBB) is set to trigger nearly $1 trillion in cuts to Medicaid in 2026. These reductions specifically target expansions previously established under the Affordable Care Act (ACA), shifting a larger share of costs to the 40 states that expanded the program. According to Julie Donohue, chair of health policy and management at the University of Pittsburgh, the reduced federal match rate will primarily affect individuals earning less than $21,000 per year.
New Work Requirements and Eligibility Restrictions
Starting in 2026, the Trump administration is implementing mandatory work requirements for Medicaid expansion enrollees. Unless exempt, recipients must complete and verify 80 hours per month of employment, education, or community service to maintain their health coverage. These requirements are part of a broader effort to eliminate what the administration defines as waste and fraud within the program.
Eligibility is also tightening for immigrant populations. New rules restrict access for lawful permanent residents, including green-card holders and Compact of Free Association (COFA) migrants. Additionally, several states are rolling back state-funded coverage for non-citizen groups, a move projected to significantly increase the number of uninsured residents.
Projected Coverage Losses
The Congressional Budget Office (CBO) estimates that these policy shifts will leave 1.3 million more Americans uninsured in 2026. Broader projections from health policy experts suggest the total number of low-income individuals losing insurance could reach 10 million as 15 separate provisions in the OBBB take effect.
The changes reflect a major pivot toward tighter fiscal control. By reducing federal spending on Medicaid, the administration aims to generate funds for broader tax cuts while focusing the program on what it defines as the most vulnerable populations.
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