We are All Immigrants Now: Trump’s Big Beautiful Bill Decimates Health Care Access for All but a Privileged Few

In March of this year, the Affordable Care Act (ACA) turned 15 as the Trump administration and GOP legislators announced potential cuts to Medicaid. An op-ed that I wrote outlined the GOP Plan to End Obamacare by fiscally starving it to death rather than an explicit repeal. Trump’s recent signing of the “Big Beautiful Bill” (BBB) brings us closer to that harsh reality.  

In addition to Medicaid cuts, expiring ACA subsidies will result in an estimated 17 million Americans losing their coverage. The reduction in Medicaid Provider taxes will likely result in hospital closures. About 500,000 health care jobs could also be lost due to these cuts. The BBB also includes non-budgetary changes such as an end to automatic reenrollment, coverage delays for life-changing events (losing a job, married, having a baby), and shorter enrollment periods.

People across the country will feel the pain, but those in rural areas and red states will be hardest hit. Simply put, the BBB erodes all the progress Obamacare made extending access to coverage. But these detrimental cuts to health care for Americans should be no surprise.

The GOP plan to Make America Sicker Again started decades ago, not through stripping benefits from Americans but by slowly curtailing immigrants’ access to the social safety net. It began with barring undocumented immigrants from Medicaid and other public benefits in the 1970s.¹ By 1996, such exclusion expanded to include some documented immigrants. For example, green card holders in the country for less than five years were targeted under the bipartisan Personal Responsibility and Work Opportunity Act (PRWORA) of 1996. Despite being documented tax-paying immigrants, they were excluded from the social safety net. By the time President Obama signed the ACA into law in 2010, most immigrants – undocumented and documented – were barred from its signature provisions.  

Over the past decade, immigrants’ exclusion has intensified under both Democratic and Republican Presidential and Gubernatorial administrations. For example, that exclusion negatively affected Latino immigrants and citizens’ health care access in Boston under the Massachusetts and Obamacare reforms.² My interviews with 200+ immigrants (Brazilians, Dominicans, and Salvadorans), health care providers, and immigration and health advocates in Massachusetts revealed the impact of expanding documentation status restrictions on health coverage in what is arguably the best place for health care in the United States.

Unfortunately, those restrictions now include citizens under the BBB. Three of my primary findings reflect what we may observe around the country as Medicaid and other health-related cuts take effect in 2027: 1) increased enforcement will hinder health-seeking behaviors; 2) increased administrative burdens will result in lost coverage; and 3) the most vulnerable will be at risk even in blue states.

First, increased immigration enforcement will dramatically reduce health-seeking behaviors, impeding health care access for those with coverage. To increase Trump’s mass deportation regime, the BBB allocates nearly $170 billion for “homeland security and immigration,” the majority of which goes to enforcement. Despite proclaiming that ICE’s focus is on criminals, there has been a surge in ICE arrests of high school and higher education students along with naturalized and US-born citizens. This enforcement will escalate: anyone can be caught in its net. Beyond that, a Trump executive order removing health care facilities designation as “sensitive locations” now means that ICE can detain people while obtaining care. 

The intensification of the socio-political climate under the Obama and first Trump administrations made immigrants fearful of leaving their homes. If raids occurred in immigrant neighborhoods or enforcement vehicles were on the streets, immigrants canceled medical appointments. This has a spillover effect in mixed-status families, where immigrant parents did not take their citizen children for medical treatment. Rachel, an immigrant advocate interviewed in 2019 shared that “a young Brazilian family, their toddler son was in [an] acute condition, and they were afraid to call in the EMT. And so, they try to drive their son to the hospital, and he died in route.”

The consequences of immigration enforcement are racialized: people of color – regardless of legal status – are more likely to be targeted and detained^.3 Much research shows this impact of profiling in law and immigration enforcement, with scholars using the term the “racialized legal status” to describe the intersection of race, ethnicity, and legal status.^3,4,5 For some of the naturalized citizens I interviewed, their racialized legal status undermined their health care access despite being citizens. 

Next, the proposed Medicaid cuts will add administrative burdens and work requirements that will lead to people losing their care.⁶ Applying for health coverage or any other public benefits has always had significant red tape. But the BBB makes it more cumbersome. Many of the immigrants and advocates I spoke with shared just how challenging enrolling in coverage was because of the confusing paperwork. Beyond that, the identity proofing process can reject applicants for any type of mistake. Maggie, a health advocate interviewed in 2015 told me that immigrants especially are likely to get errors: “because the system cannot verify their address… [or] the worker [state bureaucrat] inputs an incorrect immigration status and they [get an] erroneous eligibility decision.”  

I heard numerous accounts of immigrants being kicked off coverage due to not understanding paperwork and required documentation not being received in time. If someone moved and forgot to report their address change, they could also lose their coverage. Sometimes people learned their coverage lapsed while at a medical appointment. This happened to Magna, a Brazilian immigrant interviewed in 2019. She accumulated “close to $2,000 in bills from hospitals from when I wasn’t aware that I didn’t have insurance and was going to the doctors.” This will likely be the new normal around the country for citizens on Medicaid. Assistance from health care navigators and Medicaid staff will also be in short supply. Trump reduced funding for health care navigators after inauguration and some Medicaid staff were cut by the Department of Government Efficiency (DOGE).

Finally, BBB health-related cuts will put states in a fiscally precarious position that will further undermine everyone’s health care access. State officials will have hard budget decisions to make, trying to fill huge gaps left by federal cuts. And the most vulnerable—immigrants, low-income individuals—will be the ones on the budgetary chopping block. In terms of immigrants’ health care access, states like California, Illinois, and Minnesota that previously expanded Medicaid for undocumented immigrants are now cutting it. Though Massachusetts did not expand Medicaid for this group, it has used state funding to provide coverage to any income-eligible resident through its Health Safety Net (HSN) Program since the 2006 health reform.

But funding for that program has been reduced over time, with a Republican governor cutting the state’s contribution and lowering the income cutoff for program eligibility in 2016. The result, individuals with HSN coverage found that they no longer qualified. Carolina, a health advocate described the impact of this for her clients: “When they contact [us] here, it is sometimes too late. That’s when I tell [them], it seems like their income is too high” under the new rules. Amid a budget shortfall in 2011, a Democratic governor switched some immigrants from their health coverage to cheaper and less robust coverage that caused significant care disruptions. Both examples occurred when there were not the types of federal budget cuts we will soon see under the BBB.

What I found in greater Boston among Brazilians, Dominicans, and Salvadorans of various legal statuses is that their racialized legal status worsened their health care access amid state and federal policy changes. This was the case in the birthplace of health care reform in a wealthy blue state with world-class hospitals. Just imagine the future impact of the BBB among mostly White low-income citizens in poorer red states. Though Trump and the GOP have explicitly aired their disdain for immigrants, their “Big Beautiful Bill” shows how little they care about the health of American citizens. They are willing to sacrifice the health of the majority to fund tax cuts for a small minority of the wealthiest individuals. For them, we are all immigrants now.

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