The devastating impact of Trump's big beautiful bill, in one chart

Vox

5 hours ago

covers health for Vox, guiding readers through the emerging opportunities and challenges in improving our health. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo, and STAT before joining Vox in 2017.
While public attention has largely been focused on the Middle East and on President Donald Trump's immigration policy, Republicans in Congress are on the verge of passing massive Medicaid cuts as part of a budget bill that could lead to millions of Americans losing their health insurance benefits and, according to one recent estimate, thousands of unnecessary deaths every year.
While the GOP's so-called 'big, beautiful' bill is a smorgasbord of policy — potentially including everything from blocking AI regulation to restricting the power of the federal courts — perhaps the most consequential changes would be to Medicaid. The program, which covers low-income Americans of all ages, is now the country's single largest insurer, covering more than 70 million people. The legislation approved by House Republicans, which is now being debated and amended by the Senate, would cut Medicaid spending by $793 billion over 10 years. The upshot is that 10.3 million fewer people would be enrolled in the program by 2034.
Those coverage losses would more than undo the progress the US has made in reducing the ranks of the uninsured over the past few years. On Tuesday, the National Center for Health Statistics reported that the number of US adults without insurance in 2024 had fallen to 27.2 million, down from 31.6 million in 2020. The GOP bill would reverse those gains and then some within a decade.
The consequences would be much more severe than the mere loss of a government health insurance card. According to one analysis of the House bill published last week in the Annals of Internal Medicine by a trio of Harvard-affiliated researchers, those losses of Medicaid coverage would lead to fewer Americans reporting good health, fewer patients getting preventive health screenings, and, at the end of the day, between 8,200 and 24,600 additional annual deaths.
Senate Republicans are not going to adopt the House bill exactly as it is, which means any estimates of its effects are preliminary. But it appears likely GOP senators will keep at least two impactful provisions: new work requirements for many of the people on Medicaid and limits on the financing tools that the states can use to access more federal Medicaid funding. The Harvard study broke out the estimated effects by provision and the results are still foreboding: between 3,000 and 9,000 annual deaths attributable to Medicaid work requirements, and between 4,200 and 12,600 deaths if state provider taxes were completely eliminated.
Even short of the worst-case scenario, Americans' health would be worse off under the Republican bill, according to researchers Adam Gaffney, David Himmelstein, and Steffie Woolhandler. The number of Americans who have a personal doctor would drop by 700,000 under Medicaid work requirements; 285,000 fewer people would ever get their blood cholesterol checked, and 235,000 fewer patients would ever have their blood sugar tested. The number of women getting a recommended mammogram within the past 12 months would drop by nearly 139,000. And an additional 385,000 people would have to borrow money or skip paying other bills to afford their medical care. The people affected are low-income and disproportionately Black and Hispanic.
There is plenty of uncertainty in these projections. It is also hard to be sure how these policies would interact with each other: The Harvard researchers noted in their cumulative estimate of the House bill's effects that there would likely be some overlap in the policies' projected effects when combined together. Some of the people who lose their Medicaid coverage would be able to get insurance by other means, offsetting the losses to a degree that can be difficult to predict.
But the takeaway from the analysis is clear: A lot of people are going to suffer if these proposals become law.
The US is sabotaging its own health care system
The debate in the Senate has not yet concluded, and the bill could still change. Hospitals are busy on Capitol Hill, lobbying Republicans to reduce the spending cuts and warning lawmakers of the devastating consequences that the legislation would have. Some GOP senators are reportedly open to providing additional funding for rural hospitals, to relieve the impact on the facilities that would be hardest hit by the proposed Medicaid cuts.
But after Republicans narrowly failed to roll back Medicaid during Trump's first term, they seem likely to succeed this time — a step backward from building a true universal health care system.
America's lack of universal health care is the main reason we spend more money than any other country in the world while seeing worse outcomes. One recent JAMA analysis found that deaths that could be prevented by accessible health care increased in the United States from 2009 to 2019, while declining in most other comparable countries.
You can achieve universal health care via a variety of strategies, including the expansion of private health insurance, but the Republican bill could instead lead to more unnecessary deaths by taking existing benefits away from people, according to the Annals of Internal Medicine study.
Medicaid has actually been a rare bright spot in America's often dysfunctional health care system. The program has its own problems — not enough doctors participate because of its low reimbursement rates, for one — but since its expansion through the Affordable Care Act in 2010, research has shown that Medicaid allowed more people to access health care, reduced their financial burden from medical services, and improved their physical and mental well-being.
Republican lawmakers and Trump administration officials justify the Medicaid cuts by saying that people who can work should be required to work in order to receive government benefits. They claim nobody who deserves to be on Medicaid will lose their coverage. As one White House official put it to Politico earlier this month: 'Medicaid does not belong to people who are here illegally, and it does not belong to capable and able-bodied men who refuse to work. So no one is getting cut.' (Undocumented migrants are already ineligible for federal Medicaid funding. Six states cover undocumented adults through Medicaid using the state's own funds, and 14 cover undocumented children.)
But independent analysts say that most of the people on Medicaid are either children, elderly, disabled — or adults who are already working or caring for another person — meaning they are limited in their ability to work. Most of the projected coverage losses result from people having paperwork problems in documenting their work or proving they should be exempt from the requirements, not because people are actually ineligible under the new rules.
That aligns with the experience of Arkansas during Trump's first term. That state tested work requirements in the real world for the first time and 18,000 people lost their health insurance in a matter of months, with no meaningful effect on their employment.