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May 1, 2026
Quarterly Article
Adam Gaffney
Danny McCormick
David U. Himmelstein
Steffie Woolhandler
Apr 28, 2026
Mar 23, 2026
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Policy Points:
Context: The so-called One Big Beautiful Bill Act signed into law by President Trump on July 4, 2025 will cut $1 trillion from federal health care programs over the coming decade and cause 10 million individuals to become uninsured according to the Congressional Budget Office. Most analyses of the bill’s impacts have assumed they would be the inverse of those documented from previous coverage expansions. An examination of past coverage cuts might yield additional insights into the probable impacts of this legislation on the medical care and health of the needy.
Methods: We reviewed studies of four prior large scale coverage contractions: Reagan-era Medicaid cuts, the 2005 Tenncare Disenrollment, the 2019 implementation of work requirements in Arkansas, and the postpandemic “Unwinding” of Medicaid.
Findings: The experience of these prior coverage contractions complements evidence from analyses of coverage expansions in predicting that widespread insurance loss will lead to a reduction in care utilization, an increase in household financial strain, and worsened physical and mental health for low-income individuals. These coverage contractions additionally suggest that most who lose Medicaid coverage will not find alternative coverage; that work requirements will impose burdensome administrative costs on states; that states are unlikely to offset reductions in federal Medicaid funding with internal funds; and that the second-order effects of coverage losses may, in some instances, be greater (in magnitude) than the benefits seen after coverage expansions.
Conclusions: Cuts to federal health care programs will produce sharp contractions in public coverage that will worsen existing problems in US health care such as insurance churn, degrading care, and worsening health inequality. While states may take some steps to mitigate harmful impacts, better protection of the medically needy would require repeal of the legislation, while full protection would require universal, seamless coverage.
