Lisa Jarvis: A big, ugly attack on Americans' health

In the wee hours of Thursday morning, House Republicans pushed through President Donald Trump’s “Big, Beautiful Bill,” a proposal that dramatically cuts Medicaid, in part by imposing strict work requirements on recipients. The hastily devised plan amounts to a reckless attack on health care that covers some 83 million low-income Americans.

The bill was rushed to a vote before the nonpartisan Congressional Budget Office even had a chance to analyze its impact. However, CBO’s estimates for a previous version of the legislation anticipated the Medicaid cuts would result in about 10.3 million more uninsured Americans. Changes made in the dark of night are expected to push the number even higher. The bill now heads to the Senate.

“If this bill gets enacted, it would represent the biggest rollback in federal support for health care ever,” Larry Levitt, executive vice president for health policy at KFF posted on Bluesky.

Republicans claim their bill is crafted to protect the vulnerable — that they’re only targeting able-bodied adults who aren’t working. It carves out exemptions for people with disabilities, those who suffer from substance use disorder and parents.

However, past experience tells a different story. The changes would affect not just those in the above-mentioned groups but also pregnant women and children — and even Americans who don’t rely on Medicaid. Ultimately, as new data make clear, this attack on a vital service for low-income Americans will cost lives.

“We know that these (requirements) don’t work to encourage work, but they are very effective at having people fall through the cracks and lose their health insurance,” says Joan Alker, a professor at Georgetown University’s McCourt School of Public Policy.

Those who will be most obviously affected are people who don’t meet the work requirements — 80 hours a month in the current version. Then there are those who drop off because they can’t navigate whatever system states are able to quickly patch together to determine eligibility. Those who are able to remain covered might see fewer benefits, have fewer physicians to choose from or skip care if they can’t afford new out-of-pocket costs. Lastly, people who live in areas where health care systems are already struggling to survive may now lose access to a local hospital or specialty providers.

What a disaster.

The most immediate issue will be determining eligibility under whatever form the final law takes. Coming up with a system that doesn’t mistakenly kick qualified people off was always going to be a challenge. With each new iteration of the bill, Republicans chipped away at the time states will have to develop a strategy. First, they targeted rolling out requirements in 2029, then aimed for 2027 and, in the bill that passed, states are being asked to implement changes in late 2026.

That short window makes Medicaid experts want to tear their hair out. Getting this right is a Herculean task, one that can be costly and requires careful planning.

We’ve already seen what happens when it goes wrong. When Arkansas became the first state to implement work requirements during Trump’s first presidency, many of the people screened out of coverage were working or had a disability, said Adrianna McIntyre, a health policy expert at the Harvard T.H. Chan School of Public Health. Meanwhile, imposing work requirements didn’t lead to more people getting jobs. It only led to more individuals without health insurance.

One problem is the difficulty in reaching people. Many recipients don’t realize they risk losing coverage or must take steps to maintain it. When pandemic-era rules that automatically renewed Medicaid coverage expired in 2023, some 25 million people were kicked off their plan. McIntyre and her colleagues analyzed four Southern states to understand how that unfolded. They found that about 25% of them only discovered that they’d lost their insurance when they went to a doctor’s office or pharmacy for care.

Those who retain their public insurance will also lose out. The House bill requires states to impose cost sharing on people who fall under the expansion group, meaning their income is at or up to 138% above the poverty level. While some services like primary care or addiction treatment are exempt, not everything was covered — cancer treatment, for example, didn’t make the list.

Meanwhile, the evidence overwhelmingly shows that cost-sharing pushes people with Medicaid to forgo doctor visits and worsens their health.

Access to care could be further diminished as states devise ways to deal with the blow to their budgets. As Alkers points out, states are facing a world of hurt from this big bill — not just the Medicaid portion. Deep cuts to the Supplemental Nutrition Assistance Program and changes to Affordable Care Act marketplace plans are expected to leave even more people without insurance.

While some states might raise taxes or make cuts in other areas, like education, to maintain coverage, others could decide not to pay for Medicaid services that the law says are optional (that includes things like dental care, physical therapy, speech services and some home-based care). They might also pay doctors less for services, leading to fewer providers who are willing to accept Medicaid.

Anyone who lives in an area with tenuous health care access should pay attention to that last bit. Many hospital systems, especially in rural areas, rely on Medicaid to keep their doors open. The Center for Healthcare Quality and Payment Reform has found that about 300 rural hospitals are on the brink of closing — and 190 of them are in states with Medicaid expansion. If these cuts push them over the edge, everyone, not just individuals who rely on government insurance will be harmed.

Ultimately, people will die because of these changes. That grim reality was made clear by a new analysis from the National Bureau of Economic Research. By examining census data alongside records on Medicaid enrollment, income taxes, disability and mortality across 37 million Americans, researchers found that someone enrolled in Medicaid under the expansion was 21% less likely to die than someone whose state didn’t adopt the expansion.

And everyone benefited. It didn’t matter if people were young or old; the decline in mortality was broad and proportional across low-income adults, according to University of Chicago economist Bruce Meyer, who co-authored the study.

This rushed-through plan seems designed to do the most harm to low-income people. If eventually signed into law, we should expect to see that show up in the data in gruesome ways — millions of Americans without health care and many more who are sicker and die sooner.

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This column reflects the personal views of the author and does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.

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