The Trump administration’s policies have led to significant changes in healthcare coverage in the U.S., particularly through sweeping federal legislation and executive actions. These policies have affected Medicaid, Medicare, the Affordable Care Act (ACA) marketplaces, and healthcare affordability for millions.
The effects are nuanced and multifaceted, encompassing coverage losses, premium increases, new barriers to enrollment, and changes to immigrant eligibility.
Overview of policy shifts
Starting in January, the current administration has rolled back many healthcare expansions implemented by the Biden and Obama administrations. The focal point of this shift? The “One Big Beautiful Bill Act” which cuts more than $1 trillion from federal healthcare programs, making it the largest rollback in American history.
- This bill targets Medicaid and ACA marketplace funding, adding work requirements and eligibility checks that may result in thousands losing coverage.
- The administration also reversed executive orders that had expanded ACA enrollment windows and subsidies.
- These changes have erected barriers for low-income citizens, immigrants, and working families reliant on government support.
Medicaid: Work requirements and cuts
The administration mandated community engagement (work or training) requirements for many adults to retain Medicaid coverage. Historical evidence and current analyses show these requirements:
- Increase administrative costs and complexity for states.
- Frequently cause eligible recipients to lose coverage because of paperwork errors, not changes in eligibility.
- Don’t increase employment rates as intended.
Funding cuts and rural impact
Medicaid faces significant funding cuts, limiting states’ abilities to use provider taxes to boost payments to hospitals and managed care providers. Rural hospitals, already financially fragile (with 48% operating in the red in 2023), anticipate reductions in services; many have already closed or plan to close as much-needed Medicaid dollars disappear. And yet over 16 million people living in rural communities rely on Medicaid.
ACA’s shrinking coverage and rising premiums
Executive orders rescinded policies that expanded ACA enrollment windows, tightened eligibility verification, and limited automatic re-enrollment for ACA marketplace plans. Some analysts worry that these changes will require millions who rely on a plan to submit detailed documentation more frequently, potentially risking loss of coverage due to errors or delays. Shorter open enrollment windows make it harder for some to sign up, especially those unfamiliar with the system.
Enhanced premium subsidies, expanded in the wake of COVID-19, are set to expire, leading to immediate — and sharp — increases in out-of-pocket costs. Median ACA marketplace premiums are rising by 15% nationwide. The Congressional Budget Office projects that about 15 million people will lose ACA coverage by 2034 as costs rise and financial assistance dwindles.
The new policy also excludes many immigrants who are here legally from Medicaid and Medicare eligibility, including refugees, asylum seekers, those with Temporary Protected Status, survivors of human trafficking and domestic violence, and those granted humanitarian parole.
Medicare: Direct and indirect impacts
The administration curtails Medicare eligibility for key immigrant communities and bans improvements to Medicare Savings Programs, making coverage harder for low-income seniors and immigrants to obtain. It’s projected that lost revenues will result in Medicare’s hospital insurance trust fund running out by 2033 (three years earlier than 2024’s prediction of 2036), triggering automatic benefit cuts by 2027.
According to the Yale School of Public Health, the May 2025 House-passed reconciliation bill is projected to result in 1.38 million low-income Medicare beneficiaries losing their coverage. This loss will lead to an estimated 18,200 additional deaths annually from a lack of access to subsidized prescriptions.
The OBBBA also limits which drugs Medicare can negotiate lower prices for; it excludes expensive “orphan drugs.” In other words, the bill makes it easier for drug companies to protect these drugs from price negotiations. Specifically, the law expands protection for drugs that treat more than one disease and delays price negotiations until the FDA approves an orphan drug for treating a common disease. This change is intended to encourage biotech companies and private investors to prioritize the development of treatments for rare diseases. However, the new law could reignite the debate over striking a balance between drug innovation and the government’s goal of controlling healthcare costs.
Healthcare affordability and financial risk
Higher out-of-pocket costs
Medicare expansion states must now charge enrollees up to $35 for certain services, which reduces access for low-income adults already living on tight budgets. Policies to cut spending on health premiums, especially for middle- and low-income Americans, are causing sticker shock on the insurance exchanges. U.S. District Court Judge Sean Jordan, of Texas’s Eastern District, ruled that removing medical debt from reporting on consumer credit reports was not within the authority of the Consumer Financial Protection Bureau. Had this change been implemented, the credit scores of individuals with medical debt would have risen an average of 20 points.
Increase in uninsured and underinsured populations
With millions projected to lose insurance, uncompensated healthcare is expected to rise, threatening the financial stability of hospitals and healthcare networks, especially in rural and underserved areas. More uninsured people are likely to delay care, use emergency services more frequently, and accumulate medical debt.
Worsening medical debt crisis
According to a West Health-Gallup Healthcare Survey of over 3,500 adults conducted last year, 31 million Americans (12%) borrowed an estimated $74 billion over the course of one year to pay for their own healthcare or that of a family member. Cuts to federal health protections and Medicaid, as well as the end of ACA subsidies, are forecast to exacerbate the already severe crisis of medical debt among American households, negatively impacting health outcomes and financial security. According to KFF, the average premium is expected to increase by 75% (approximately $700 more) in 2026.
Impact on immigrants and vulnerable populations
The policies restrict access for lawfully present immigrants across Medicare, Medicaid, and ACA, upending long-established eligibility paths for different groups. By 2027, current immigrants who don’t meet the narrowed definitions will lose coverage, regardless of prior work or residency.
Policy rationale vs. expert analysis
The administration argues that these changes address “fraud” and federal overspending, maintaining that work requirements and stricter eligibility checks will improve system integrity. However:
- Major health and policy organizations counter that these cuts and policy shifts compromise coverage, affordability, and the stability of the health system in pursuit of ideologically driven cost savings.
- Research consistently shows that administrative hurdles and cuts lead to eligible people losing coverage and do not meaningfully increase workforce participation among Medicaid recipients.
Blocking implementation of nursing home standards
The U.S. Department of Justice is appealing a court decision that blocked a new federal rule for nursing home staffing. In April, a Texas judge ruled that the Department of Health and Human Services (HHS) overstepped its authority by creating requirements for a 24/7 registered nurse and a minimum of 3.48 hours of nursing care per resident per day.
The government is seeking to reinstate these rules, arguing that they’re essential for resident safety and fall within the Centers for Medicare & Medicaid Services’ existing authority to regulate healthcare providers. The current proposed budget includes a provision delaying the implementation of this staffing mandate until at least January 1, 2035.
What’s next?
The Trump administration’s healthcare policies mark a dramatic reversal of the expansions accomplished under the Obama and Biden administrations. As these measures take full effect, their full consequences will take years to become apparent. Current evidence points to rising uninsured rates, reduced service availability, and increasing medical debt, leaving the American healthcare landscape even more precarious for millions of people.
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