The One Big Beautiful Bill Act (OBBBA) became law on July 4, cutting more than $1 trillion in Medicaid funding and making substantial changes to the federal student loan program.
When the U.S. House first introduced the legislation, the Congressional Budget Office (CBO) estimated that more than 10.3 million people could lose Medicaid coverage, with 7.6 million becoming uninsured. Although the final package has not yet been analyzed by the CBO, early projections of the U.S. Senate's initial legislative text estimated that up to 17 million individuals could be impacted.
These cuts will likely have lasting effects on patient care, leading to more people relying on emergency services in place of routine preventive care. In addition, rural hospitals may face increased financial strain, potentially jeopardizing their ability to remain operational and continue serving their communities.
View additional details and implementation dates on Medicaid provisions and other key measures of note for cardiovascular clinicians below.
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Provision Topics |
Provision Included in Final Passage of OBBBA (H.R. 1) |
Implementation Date |
| Key Student Loan Provisions |
Student Loan Caps |
- Caps the amount of federal unsubsidized loans that a medical student may obtain in any academic year at $50,000.
- Sets the maximum aggregate limit for unsubsidized loans for medical students at $200,000.
- Terminates Grad PLUS loans for students but exempts students with an existing loan. Students who have received a Grad PLUS loan as of June 30, 2026, will continue to receive those loans until the 2029-2030 academic year.
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Effective July 1, 2026 |
| Student Loan Plans |
New loans can only be repaid using two new plans:
- Standard plan with fixed monthly payments and terms ranging from 10 to 25 years based on the amount borrowed.
- Income-based repayment assistance plan (RAP).
Borrowers with no new loans made on or after July 1, 2026, can continue to enroll in current plans or opt into a new RAP. Current borrowers must transition to a new repayment plan b July 1, 2028. If no selection is made by that date, they will be automatically moved to RAP. |
Effective July 1, 2026 |
| Key Medicaid Provisions |
Enrollment Verification |
- Requires establishment of a system to prevent simultaneous enrollment in Medicaid in more than one state.
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Effective Oct. 1, 2029 |
| Eligibility |
- Redeterminations must be made every six months.
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Effective Dec. 31, 2026 |
| Deceased Beneficiaries/Providers |
- Requires states to review the Master Death File quarterly to eliminate all deceased Medicaid beneficiaries and providers.
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Effective Jan. 1, 2027 |
| Citizenship/Immigration Status Verification |
- Eliminates the requirement for states to provide coverage during the reasonable opportunity or other allowable periods.
- States may elect to provide coverage to applicants during such period, but beginning Oct. 1, 2026, federal medical assistance percentage (FMAP) payments will not be made to a state unless the person is of a specified citizenship or immigration status.
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Effective Oct. 1, 2026 |
| FMAP |
- Eliminates the 5% traditional FMAP increase (which was provided for a two-year period) for states that implement Affordable Care Act (ACA) Medicaid expansion.
- Does not affect states currently receiving the increase, but no future increases will be provided.
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Effective Jan. 1, 2026 |
| Provider Taxes |
- Phases out the ceiling of provider taxes for ACA expansion states, beginning at 6% in 2027 and decreasing to 3.5% in 2032.
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Beginning in 2028, threshold decreases by 0.5% per year. |
| Rural Hospital Support |
- Allocates $50 billion to support rural hospitals.
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Hospitals must submit application for funds by Dec. 31, 2025. |
| Retroactive Coverage |
- Medicaid expansion population receives one month of retroactive coverage.
- Traditional Medicaid population receives two months of retroactive coverage.
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Effective Dec. 31, 2026 |
| Work Requirements |
- Implements work requirements for able-bodied adults (aged 19 to 64) without dependents.
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No later than Dec. 31, 2026, or earlier at state option |
| Cost Sharing Requirements |
- Requires states to impose cost-sharing up to $35 per service on ACA expansion adults with incomes 100-138% Federal Poverty Line, with an annual cap of 5% of family income.
- Exceptions for primary care, mental health and substance abuse services, and services provided by a Federally Qualified Health Center or certified community behavioral health clinic or rural health clinic.
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Effective Oct. 1, 2028 |
| Other Notable Provisions |
ACA Exchanges |
- Excludes non-lawfully admitted people from eligibility for the premium tax credit. The bill also effectively ends auto-reenrollment and provisional enrollment for customers beginning with tax year 2028.
- Requires verification of key application details – income, immigration and coverage status, residence, and family size – to qualify for exchange plans and the Premium Tax Credit (PTC) and disallows the PTC for those enrolled during an income-based special enrollment period not tied to a change in other circumstances.
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Effective Dec. 31, 2026 (excluding non-lawful individual)
Effective Dec. 31, 2027 (all other provisions) |
| Medicare Coverage |
- Asylum recipients, refugees and individuals with temporary protected status will no longer qualify for coverage and will lose access 18 months after enactment.
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Effective Jan. 1, 2027 |
| Telehealth Flexibility |
- Permanently extends the safe harbor for first-dollar coverage of certain telehealth services for individuals with HSA-eligible high-deductible health plans, allowing them access to certain telehealth services without having to first meet their deductible.
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Effective Jan. 1, 2025 |
| Medicare Payment Relief |
- A one-time, temporary payment increase of 2.5% for 2026 under the Medicare Physician Fee Schedule.
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Effective Jan. 1, 2026 |
Now at the end of this year's reconciliation process, ACC Advocacy will continue championing policies that support both clinicians and patients, including building on the 2026 payment relief provision by advocating for long-term Medicare payment reform legislation. Additionally, Medicare telehealth flexibilities are set to expire on Sept. 30. The College will continue its efforts to make these flexibilities permanent.
Stay informed at ACC.org/Advocacy and through the weekly ACC Advocate newsletter.
Keywords:
Medically Uninsured, Hospitals, Rural, United States, ACC Advocacy, Medicaid, Patient Care
