What You Need to Know
By Jamie Shoemaker, MD, FACEP
The recently introduced “One Big Beautiful Bill Act” brings sweeping changes to Medicaid, Medicare, the ACA, student loans and rural health policy—many of which will directly impact facility-based providers and the vulnerable patients they serve.
Medicaid Overhaul
Several provisions target Medicaid eligibility and payment:
- Deceased and multi-state enrollment checks aim to reduce improper payments.
- Eligibility redetermination every 6 months for the expansion population will likely increase coverage churn.
- Eligibility limited to specific legal residents, cutting coverage for some non-citizens.
- Medicaid funding for undocumented immigrants will shrink.
- Retroactive coverage reduced from 3 to 1–2 months, making it harder for physicians to recover costs.
- Work requirements and mandatory copays will be introduced for certain expansion adults.
- Payment reforms will cap provider reimbursements and reduce allowable state-directed Medicaid payments to Medicare-level rates, especially impacting expansion states.
- Medicaid expansion incentives end in 2026, potentially discouraging new states from expanding.
Affordable Care Act (ACA)
- Marketplace subsidies will be limited to lawfully present residents.
- Auto-renewals for plans will be phased out, requiring active re-enrollment.
- Without extending enhanced subsidies, 4 million people could lose coverage by 2026.
Medicare
- Like Medicaid and the ACA, eligibility will be limited to lawful residents.
- A temporary 2.5% bump to the Medicare physician fee schedule in 2026 will slightly offset recent cuts to the physician fee schedule.
Student Loan Reform
- Loan caps will tighten. Medical students face a $200,000 total limit, and Grad PLUS loans will be eliminated.
- New income-driven repayment plans will replace SAVE and PAYE, potentially raising monthly payments and reducing forgiveness options.
Rural Health Investment
A new $50 billion Rural Health Transformation Program will support innovative models and access improvements in underserved areas over five years.
Bottom Line
This legislation introduces major changes with wide-reaching implications for our physicians, patient access, and provider reimbursement. From Medicaid work requirements to reduced retroactive coverage, the bill could create administrative and financial burdens while narrowing access for vulnerable populations. Meanwhile, short-term Medicare payment relief and rural health funding offer modest support amid broader cuts and restrictions.
About Jamie Shoemaker
Jamie Shoemaker, MD, FACEP, is an Emergency Medicine Strategic Advisor with Ventra Health. A distinguished Emergency Medicine physician, Dr. Shoemaker has more than 25 years of clinical experience. He is also a leader in the ACEP community and a well-known government advisor who has spent decades shaping physician reimbursement policy and legislation at both the Federal and state levels. He is currently an Emergency Medicine Partner with Vituity in Elkhart, Indiana, and will continue to practice medicine alongside his new role at Ventra.
