Reconciliation law projects leaving 10M uninsured
The largest Medicaid cut in history imposes work requirements and eligibility redeterminations.
Key facts
- CBO: 10M additional uninsured by 2034
- $990B in gross Medicaid/CHIP cuts over 10 years
- 1.3M uninsured added in 2026 alone
Summary
President Trump signed the "One Big Beautiful Bill Act" on July 4, 2025. The law imposes Medicaid work requirements, semi-annual eligibility redeterminations, provider-tax restrictions, and ACA marketplace changes. CBO estimates the law will increase the number of uninsured Americans by 10 million by 2034, with $990 billion in gross Medicaid and CHIP spending cuts over 10 years - the largest in program history.
What happened
The reconciliation law's primary Medicaid provisions include: 80-hour-per-month work/school requirements for adults 19-64 (effective 2027; CBO: 5.3 million uninsured by 2034); semi-annual rather than annual eligibility redeterminations for expansion adults (CBO: 700,000 uninsured); restrictions on provider taxes used by states to draw federal matching funds (CBO: 1.1 million uninsured); and elimination of ACA marketplace subsidies for lawfully present immigrants (CBO: 900,000 uninsured). Enhanced ACA premium tax credits also expire December 31, 2025, per the law's omission - CBO projects 4.2 million additional uninsured through 2034. Coverage losses phase in rapidly: 1.3 million uninsured added in 2026, rising to 10 million by 2034.
Impact on the United States
10 million Americans projected to lose health coverage by 2034; coverage losses start in 2026; disproportionate impact on low-income adults, children, immigrants, and rural communities dependent on Medicaid expansion; hospitals face reduced reimbursement.
Documented effects
- CBO (August 2025): 10 million additional uninsured by 2034; $990B gross Medicaid/CHIP cut over 10 years[1][3][4]
- 1.3 million uninsured added in 2026 alone; Medicaid work requirements account for majority of projected losses[2][5]
- Enhanced ACA premium tax credits expired December 31, 2025, projected to add 4.2 million uninsured by 2034[2]
- CMS issued an interim final rule on June 1, 2026 implementing the law's requirement of 80 hours a month of work or other qualifying activities for non-pregnant adults 19-64 in the Medicaid expansion group; states must implement it by January 1, 2027[6]
Projected cost to Americans
Cumulative cost if current policy holds: direct federal cost plus the broader economic burden. A conservative, lower-bound estimate (medium confidence).
- So far
- $0
- By 2035
- $144.00B
- By 2040
- $144.00B
How this is calculated: [Marks the bill's single largest SAVING (the Medicaid/CHIP/Marketplace cuts); the tax-cut COST side, including ALL of the law's revenue effects, is booked under obbba-reconciliation-law.] Layer 1 (direct federal): rebased on CBO's cost estimate for the ENACTED law (P.L. 119-21, July 21, 2025, Table 7, Title VII Subtitle B "Health") [S1], replacing an unsourced -$700B figure that cited the House-passed bill. CBO: Subtitle B changes federal outlays by -$1,058.4B over FY2025-2034 (Medicaid chapter incl. work requirements -$325.6B, provider taxes -$191.1B, state directed payments -$149.4B; Marketplace premium-tax-credit outlays -$213.0B; interactions +$95.4B; Rural Health Transformation fund +$47.2B; Medicare items +$1.7B net). The subtitle also lowers revenues by $27.8B, which is NOT counted here because obbba-reconciliation-law books the law's total revenue change; outlays only = net_cost_10yr_usd -1,058,000,000,000 (CBO window FY2025-2034; nothing added for FY2035). 15yr (through 2040) = -$1,058B plus FY2035-2040 at CBO's 10-year average pace (~$105.8B/yr x 6 = -$635B) = -$1,693B; this is conservative, since CBO's FY2034 figure alone is -$193.7B. Layer 2 (broader, borne by Americans, not a federal outlay): uncompensated care for people CBO projects will lose coverage under the enacted law (1.3M more uninsured in 2026, 5.2M 2027, 6.8M 2028, 8.6M 2029, rising steadily to 10M by 2034 [S5]; 2030-2033 linearly interpolated = ~69.1M uninsured person-years 2026-2034) x CAP's estimate of uncompensated care per full-year uninsured person, $2,263 in 2034, which CAP built from KFF's $1,455 (2017) grown 2.6% a year (the health-services producer price index); the same 2.6% rate gives ~$1,840 for 2026 [S3]. Result ~$144B through 2034, booked as $144B. Like Layer 1, it stops at CBO's last projection year (2034) and adds nothing for FY2035 (replaces an earlier $200B that assumed near-full effect from year one). This counts only uncompensated care (not excess illness, mortality or lost productivity) and excludes the separate expiration of the enhanced ACA premium tax credits (in CBO's baseline, not part of this law). Confidence medium: the federal side is CBO-scored; the Layer-2 per-person cost is CAP's (partisan think tank) estimate built on House-bill coverage numbers.
Why this is rated critical
The largest Medicaid cut in history is projected to leave 10 million Americans uninsured, a systemic and enacted harm to vulnerable populations nationwide.
Corrections & updates [5]
Every change to a fact on this page after publication is logged here, newest first.
- CorrectedSource
Source s1 was labeled 'CBO via AHA' and Tier 1. It is an American Hospital Association news item summarizing CBO's estimate, not a CBO record, so it is relabeled Tier 3. A Tier 2 report (CNN, July 21, 2025) on the same CBO estimate of 10 million more uninsured in 2034 is added.[4]
- CorrectedSource
The 1.3 million figure for 2026 was cited to KFF, which does not contain it. It comes from CBO's August 2025 coverage estimates as summarized by Georgetown CCF (1.3 million more uninsured in 2026, rising to 10 million by 2034). The citation is corrected; the figure is unchanged.[5]
- UpdatedKey facts
Updated: CMS issued an interim final rule on June 1, 2026 implementing the law's 80-hour monthly Medicaid work requirement for adults 19-64 in the expansion group. States must implement it by January 1, 2027.[6]
- CorrectedCost estimate
Corrected source labels in the cost estimate: KFF, Georgetown CCF and the Center for American Progress are analysis or advocacy sources and are now labeled Tier 3, and the CBO citation now links to the specific CBO estimate rather than the CBO homepage.
- CorrectedCost estimate
Rebased on CBO's score of the enacted law (P.L. 119-21): the health provisions cut federal outlays by $1.058 trillion over FY2025-2034. This replaces an unsourced -$700B figure that had also cited the House-passed bill. The mid-2026 saving is now CBO's own FY2026 estimate, pro-rated, instead of an unsourced guess. The broader cost is recomputed from CBO's year-by-year coverage losses under the enacted law (2026-2034) multiplied by the Center for American Progress's per-person uncompensated-care estimate, using CAP's own 2.6% annual cost growth.
- Previously
- net -$5B so far (gross $3B, saved $8B); 10yr -$700B; 15yr -$1.1T; broader $200B
- Now
- net -$15.1B so far (gross $1.3B, saved $16.4B); 10yr -$1.058T; 15yr -$1.693T; broader $144B
Sources [6]
- T3American Hospital Association (AHA News), summarizing CBO - CBO projects OBBBA to increase uninsured by 10 million, federal deficit by $3.4 trillion · Jul 21, 2025 ↗
- T3KFF - Health Provisions in the 2025 Federal Budget Reconciliation Law · Aug 4, 2025 ↗
- T3Georgetown Center for Children and Families - Medicaid, CHIP, and ACA Marketplace Cuts in the Budget Reconciliation Law, Explained · Jul 22, 2025 ↗
- T2CNN - 10 million more people will be uninsured because of Trump's mega-package, CBO forecasts · Jul 21, 2025 ↗
- T3Georgetown Center for Children and Families - New CBO Health Coverage Estimates of Budget Reconciliation Law · Aug 14, 2025 ↗
- T1CMS - Medicaid Community Engagement Requirement for Certain Individuals Interim Final Rule with Comment Period (CMS-2454-IFC) · Jun 1, 2026 ↗
Image: Jeffrey Beall, CC BY 4.0 (Wikimedia Commons)