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H.R.1, The One Big Beautiful Bill Act, passed the Senate and the House with a big cut to healthcare. Over $1,000,000,000,000 - yes, that is one trillion dollars - is taken out of Medicaid, Medicare and commercial insurance packages. The bill should be known as H.R.1, The Health and Tax Bill, because it is really about healthcare access and taxes. This column could be very long if I talked about all the pieces of the bill, so for our purpose I will focus on Medicaid and the impact of this bill on older adults.
Medicaid is the Long-Term Care Health System in this country. More than 7.5M people who are 65 and older and approximately 8.5M adults aged 50 to 64 rely on Medicaid coverage. This includes those enrolled through the Affordable Care Act (ACA) Medicaid expansion and other pathways. In addition, nearly 15M people with disabilities rely on Medicaid. For all these people, Medicaid is the only source of home and community-based services and the only payer for long-term care. The Congressional Budget Office projects that nearly 11M people will lose their insurance and 1.3M older adults will lose financial assistance to pay out-of-pocket Medicare costs.
Older adults are, in general, a very vulnerable sector of our society. The 2022 US Census Bureau report lists the median income of individuals aged 65 and older as $29,740. Therefore, one-half of older people in this country have an annual income less than $29,740. Medicaid eligibility is based on the Federal Poverty Level (FPL) which in 2025 was $15,650. Under the ACA, states can expand Medicare to 138% of the FPL which is $24,826 and some states have gone a bit higher than that. As many of our older adults live near the poverty line, one acute event and out-of-pocket expenses can make meeting necessary day-to-day expenses impossible. This bill eliminates Medicaid expansion, bringing income eligibility levels even lower.
Access to care will be impacted across the healthcare continuum as reductions in payment for providing care to people covered by Medicaid will affect hospitals and clinics. This reduction will particularly impact rural and urban areas that care for poorer sectors of our society and are already designated as medically underserved. We will see hospital and clinic closures, thereby reducing the accessibility to a needed acute care bed or a primary care visit.
Reduction in the Medicaid budget will be done by various mechanisms including reducing the amount of dollars the federal government provides to states for their Medicaid programs, making eligibility requirements more difficult for people to enroll, and reducing the Federal Medical Assistance Percentage (FMAP) which is amount of Federal matching funds provided to each State for assistance in payments for certain social services, medical and medical insurance expenditures. The FMAP varies from state to state as it is calculated from a formula that considers the average per capita income for each State relative to the national average.
Medicaid is the primary source of payment for Home and Community Based Services (HCBS) and nursing home care. These cuts could result in less people being eligible for HCBS forcing them to move into a nursing home, which costs more money than home based services, or require a family member or friend to leave the workforce to care for them. And, with these cuts, nursing homes will become less accessible as the long-term care workforce will need to be reduced to be in line with the reduction in funding. Medicaid payments to nursing homes are already lower than the cost of providing the care. Further cuts will force many nursing homes to close and those that remain open won’t have the capacity to absorb the growing older population or the staff to care for them. People will die sooner than they should have.
Medicaid cuts will have broad and detrimental consequences for older adults, affecting their access to healthcare, financial security, and overall well-being. Everyone in this country has a loved one who is old or will be one day. It is the responsibility of all to advocate for older adults and ensure that they live their lives with dignity and respect. I recall a quote from Hubert Humphrey that is notably inscribed in the entrance hall of the Health and Human Services (HHS) Administration building in Washington, D.C. I have used this quote once before in this column, but it seems more appropriate now than ever:
"The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy, and the handicapped.”
The impact of this bill on these populations will evolve over time, but sustained advocacy is needed to address both short-term and long-term consequences. We need to engage with policy makers at all levels of government to express concerns and propose solutions to mitigate the impact of this bill. We need to educate consumers and build public support, and we need to use personal stories and data to highlight the consequences of this bill.
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