After the Big and Beautiful Bill: Impacts on Disability and Health Policy

By: Noelle Pedersen

The One Big and Beautiful Bill Act, otherwise known as OBBBA, was signed into law by President Trump on July 4th, 2025. This bill addresses almost every sector of the American economy, which will greatly alter policies affecting various groups and sectors. 

Medicare, Medicaid, and Medi-Cal

To further understand the changes being made to Medicare and Medicaid, and consequently, the effects on the individuals currently utilizing them, it is essential to have a clear understanding of what these programs are.

Medicare, Medicaid, and Medi-Cal are often used interchangeably despite having several key differences. All three are programs meant to provide aid and relieve financial burdens for those who need more healthcare and services that would otherwise drain individuals financially. According to the Department of Healthcare Services, “Approximately 6.6 million Californians are enrolled in Medicare, including 5 million Medicare-only beneficiaries, and 1.6 million beneficiaries dually eligible for Medicare and Medi-Cal" (DHCS). Medicare is federal health insurance for Americans 65 years of age or over, as well as people under 65 with certain disabilities or conditions. As Medicare is a federally run program, there are set standards for costs and coverage that remain consistent across states. Medicaid is a government program, while Medi-Cal is a California-centered version of those same services. The federal government sets several general rules, but outside of those, each state runs its own program. Medicaid helps to cover health costs for many with low income and limited resources. Depending on specific eligibility criteria, Medicaid provides services that Medicare does not usually cover, such as nursing homes and in-home care and services (US Department of Health and Human Services). Previously, similar to most other states, California considered an individual’s assets when determining eligibility for Medicaid coverage. This has created many issues for disabled people economically, as owning a house or car could prevent them from obtaining coverage for needed services. Without coverage, it is very difficult to pay for such high healthcare costs, causing a cycle of poverty and overall, preventing people with disabilities from having secure housing and transportation (as well as other assets that they could leave to their children and/or use to accrue wealth over generations). As of January 2024, California has eliminated consideration of assets when determining Medi-Cal eligibility. This is a major stride in improving accessibility to services and allowing people with disabilities financial freedom. Though it is important to note that both Medi-Cal and Medicare continue to consider income for coverage eligibility.

Americans with Disabilities Act and the Affordable Care Act

Often, people with disabilities require higher levels of healthcare than the average person. This makes these services necessary for both their physical health and economic prosperity. The Americans with Disabilities Act (ADA) was instituted in 1990 as one of the early acts protecting people with disabilities in the United States. ADA is a civil rights law meant to ensure equality of opportunity in employment, services open to the public, and transportation. (ADA National Network). This act has made leaps forward for people with disabilities by making many public spaces more accessible and even enterable. Title II of the ADA covers medical services and facilities run by the government (public hospitals, clinics, and medical offices), while Title III covers private hospitals and medical practices, as they are considered public accommodations. Essentially, places that provide healthcare and similar resources are required to be as available to people with disabilities as to the general public. However, this does not mean that expenses are covered or that these communities are often offered life-sustaining services as a right.  

The current cuts on healthcare provisions through the Big and Beautiful Bill are unsurprising to many, as experts predicted these actions to be made by the current administration. The ACA often combines with the ADA to allow disabled people in California to obtain health insurance. However, many have predicted challenges that the ACA will face under the Trump Administration. Though President Trump has been quoted several times, stating that he intends to repeal the act altogether, most believe that it is unlikely to happen under the current congressional voting system (Armour, 2024). Even in the case of inaction, the Congressional Budget Office projected, “An additional 1.7 million uninsured people, on average, each year between 2024 and 2033” (Hale, 2024). As insured rates decline, access to health care will decrease.  

The Big and Beautiful Bill 

The institution of the Big and Beautiful Bill was in many ways the fulfillment of those predictions, making drastic cuts to healthcare funding as well as programs including Medicare and Medicaid. Medicaid’s Children’s Health Insurance Program (CHIP) benefits are projected by the nonpartisan Congressional Budget Office (CBO) to be cut by $1.02 trillion, due in part to eliminating at least 10.5 million people from the programs by 2034 (Ives-Rublee, 2025). In addition, there are new federal limits on Medicaid eligibility and restrictions on states’ ability to raise revenue to fund their Medicaid programs. As a result, states will be forced to supplement the entirety of lost funding themselves (through reevaluation of their current budgets or by cutting already underfunded programs). 

According to the Center for American Progress, “When federal funding for Medicaid decreases, states tend to cut optional benefits such as home- and community-based (HCBS) first” (Ives-Rublee, 2025). Supporters of the Big and Beautiful Bill argue that the new restrictions on eligibility will limit government subsidization of individuals choosing not to work; however, a study conducted in 2023 found that most Medicaid adults under the age of 65 were already working. In fact, of Medicaid-covered adults who do not receive benefits from SSI or SSDI and are also not covered by Medicaid, 92% were working full or part-time (64%), or not working due to caregiving responsibilities, illness or disability, or school attendance. The remaining 8% of Medicaid adults reported that they are retired, unable to find work, or were not working for another reason (Tolbert, 2025). 

Further, the Big and Beautiful Bill requires evidence of having worked, having engaged in community service, having received work training for at least 80 hours per month, or having been enrolled in school part-time, with some exceptions. This would leave over 2.6 million adults with disabilities, who don’t have SSI or SSDI and have difficulty working, unable to qualify for Medicaid. The Bill’s cuts on Medicaid will also put rural hospitals at additional risk.

Medicare funding has also decreased under OBBBA. The bill will have many impacts, such as additional massive cuts to healthcare, reductions to SNAP (the Supplemental Nutrition Assistance Program, formerly known as food stamps), elimination of Medicare eligibility for many lawfully present immigrants (regardless of how long they have worked and paid into the system,) and blocked improvements to the Medicare savings program (which has helped lower-income Medicare beneficiaries pay for premiums and out-of-pocket costs), ultimately blocking the implementation of national minimum staffing requirements for nursing homes and limiting Medicare’s Ability to Negotiate Drug Prices (Center for Medicare Advocacy, 2025). These Medicare and Medicaid cuts come in addition to many new policies that actively target lower-income recipients of government services. Essentially, adults with disabilities, who experience poverty at over double the rate as those without, will be disproportionately affected (Goodman, 2019).  

Expected Impact

The over $1 trillion cut from health programs by the Big and Beautiful Bill is considered by several scholarly reports to be the biggest rollback of federal support for health care in American history. The Congressional Budget Office estimates that these cuts will result in an estimated 10 million people losing their health insurance coverage (CBO, 2025). Additionally, changes to the Affordable Care Act will result in another five million individuals losing insurance by the end of 2025 alone (Swagel, 2025). Those who remain insured will likely experience understaffing, strained and underfunded services, and a reduction, if not elimination, of in-home services that benefit individuals with disabilities who may have mobility or transportation issues. Without proper healthcare, individuals with disabilities’ quality of life is likely to decrease, exacerbated by the high disabled poverty rate that makes it difficult for people to afford healthcare and crucial services without these assistive programs. Considering the lasting negative effects of the COVID-19 pandemic, The Big and Beautiful Bill may have simply been the prolonging of an existing problem, rather than the creation of a new one, but for the majority of individuals with disabilities in the United States, it is progress in the wrong direction. 

References

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