Senate Republicans have passed President Donald Trump’s “big, beautiful bill,” a move that will make major changes to Medicaid through establishing a work requirement for the first time and restricting states’ ability to finance their share of the program’s costs. If the bill ultimately becomes law after passing the House and receiving Trump’s signature — which could all happen before Friday — American health care is never going to be the same.

The consequences will be dire.

The Congressional Budget Office estimates that the legislation would slash Medicaid spending by more than $1 trillion and that nearly 12 million people would lose their health insurance. Republicans added a last-minute infusion of funding for rural hospitals to assuage moderates skittish about the Medicaid cuts, but hospitals say the legislation will still be devastating to their business and their patients.

When combined with the expiration of Obamacare subsidies at the end of this year, which were not addressed in the budget bill, and the other regulatory changes being made by the Trump administration, the Republican policy agenda could lead to an estimated 17 million Americans losing health coverage over the next decade, according to the health policy think tank KFF.

Fewer people with health insurance is going to mean fewer people getting medical services, which means more illness and ultimately more deaths.

One recent analysis by a group of Harvard-affiliated researchers of the House Republicans’ version of the budget bill (which included the same general outline, though some of the provisions have been tweaked in the Senate) concluded that 700,000 fewer Americans would have a regular place to get medical care as a result of the bill. Upward of 200,000 fewer people would get their blood cholesterol or blood sugar checked; 139,000 fewer women would get their recommended mammograms. Overall, the authors project that between 8,200 and 24,600 additional Americans would die every year under the Republican plan. Other analyses came to the same conclusion: Millions of Americans will lose health insurance and thousands will die.

After a painful legislative debate in which some of their own members warned them not to cut Medicaid too deeply, Republicans succeeded in taking a big chunk out of the program to help cover the costs of their bill’s tax cuts. They have, eight years after failing to repeal Obamacare entirely, managed to strike blows to some of its important provisions.

So, for better or worse, they own the health care system now, a system that is a continued source of frustration for most Americans — frustrations that the Republican plan won’t relieve. The next time health care comes up for serious debate in Congress, lawmakers will need to repair the damage that the GOP is doing with its so-called big, beautiful bill.

How the Republican budget bill will drive up health care costs for everyone

The effects of the budget bill won’t be limited only to the people on Medicaid and the people whose private insurance costs will increase because of the Obamacare funding cuts. Everyone will experience the consequences of millions of Americans losing health coverage.

When a person loses their health insurance, they are more likely to skip regular medical checkups, which makes it more likely they go to a hospital emergency room when a serious medical problem has gotten so bad that they can’t ignore it any longer. The hospital is obligated by federal law to take care of them even if they can’t pay for their care.

Those costs are then passed on to other patients. When health care providers negotiate with insurance companies over next year’s rates, they account for the uncompensated care they have to provide. And the fewer people covered by Medicaid, the more uncompensated care hospitals have to cover, the more costs are going to increase for even people who do have health insurance. Republicans included funding in the bill to try to protect hospitals from the adverse consequences, an acknowledgement of the risk they were taking, but the hospitals themselves are warning that the funding patches are insufficient. If hospitals and doctors’ offices close because their bottom lines are squeezed by this bill, that will make it harder for people to access health care, even if they have an insurance card.

The effects of the Republican budget bill are going to filter through the rest of the health care system and increase costs for everyone. In that sense, the legislation passage marks a new era for US health policy. Since the Affordable Care Act passed in 2010, Democrats have primarily been held responsible for the state of the health care system. Sometimes this has been a drag on their political goals. But over time, as the ACA’s benefits became more ingrained, health care became a political boon to Democrats.

Going forward, having made these enormous changes, Republicans are going to own the American health care system and all of its problems — the ones they created and the ones that have existed for years.

The BBB’s passage sets the stage for another fight on the future of American health care

For the past decade-plus, US health care politics have tended to follow a “you break it, you buy it” rule. Democrats discovered this in 2010: Though the Affordable Care Act’s major provisions did not take effect for several years, they saw their popularity plummet quickly as Republicans successfully blamed annual premium increases that would’ve occurred with or without the law on the Democrats and their new health care bill. Voters were persuaded by those arguments, and Democrats lost Congress in the 2010 midterms.

But years later, Americans began to change their perception. As of 2024, 44 million Americans were covered through the 2010 health care law and two-thirds of the country say they have a favorable view of the ACA. After the GOP’s failed attempt to repeal the law in 2017, the politics of the issue flipped: Democrats scored major wins in the 2018 midterms after successfully campaigning against the GOP’s failed plan to repeal the ACA. Even in the disastrous 2024 election cycle for Democrats, health care policy was still an issue where voters trusted Kamala Harris more than Trump.

Trump’s One Big Beautiful Bill is already unpopular. Medicaid cuts specifically do not poll well with the public, and the program itself is enjoying the most popularity ever since it was first created in 1965. Those are the ingredients for a serious backlash, especially with government officials and hospitals in red states railing hard against the bill.

Democrats have more work to do on explaining to the public what the bill does and how its implications will be felt by millions of people. Recent polling suggests that many Americans don’t understand the specifics. A contentious debate among Republicans, with several solitary members warning against the consequences of Medicaid cuts, have given politicians on the other side of the aisle good material to work with in making that case: Democrats can pull up clips of Sen. Thom Tillis (R-NC) on the Senate floor, explaining how devastating the bill’s Medicaid provisions would be to conservative voters in Republican-controlled states.

Republicans will try to sell the bill on its tax cuts. But multiple analyses have shown the vast majority of the benefits are going to be reserved for people in higher-income brackets. Middle-class and working-class voters will see only marginal tax relief — and if their health care costs increase either because they lose their insurance or because their premiums go up after other people lose insurance, then that relief could quickly be wiped out by increased costs elsewhere. That is the story Democrats will need to tell in the coming campaigns.

Medicaid has served as a safety net for tens of millions of Americans during both the Great Recession of 2008 and since the pandemic recession of 2020. At one point, around 90 million Americans — about one in four — were covered by Medicaid. People have become much more familiar with the program and it has either directly benefited them or helped somebody that they know at a difficult time.

And difficult times may be coming. Economists have their eyes on concerning economic indicators that the world may be heading toward a recession. When a recession hits — that is, after all, inevitable; it’s just the normal cycle of the economy — people will lose their jobs and many of them will also lose their employer-sponsored health insurance. But now, the safety net is far flimsier than it was in previous crises.

Republicans are going to own those consequences. They took a program that had become an essential lifeline for millions of Americans and having schemed to gut the law ever since the Democrats expanded Medicaid through the ACA more than a decade ago, have finally succeeded. This Republican plan was a reaction to their opponent’s most recent policy overhaul; the next Democratic health care plan will need to repair the harms precipitated by the GOP budget bill.

In the meantime, the impetus is on Democrats and truth tellers in the media to help Americans understand what has happened, why it has happened, and what the fallout is going to be.

The Republican Party is trying to get a major tax and spending bill done before Memorial Day. It’s chock full of President Donald Trump’s legislative priorities, and has many provisions the GOP has long been agitating for. But it’s nevertheless been a massive struggle to get the bill to the House floor for a vote. One big reason is a tax provision known as SALT — the state and local tax deduction.

I asked Today, Explained’s Devan Schwartz — who just produced the below podcast about this bill — to explain what SALT is, why it’s important, and why it’s roiled the GOP. Here’s what he had to say:

SALT is an acronym that stands for “state and local taxes” — it allows Americans to deduct some of what they pay, right now up to $10,000, in state and local taxes (like property taxes and sales taxes) from their federal taxes.

Once, there wasn’t a cap to how much you could deduct, but that changed with Trump’s tax cuts in 2017; those brought in the $10,000 cap.

Removing the SALT cap is seen as benefiting mostly wealthy earners in high-tax states like California or New York: people who might make $500,000 a year or $10 million a year and pay tens or hundreds of thousands in state and local taxes, the sort of people who don’t take the standard deduction.

It’s not April; why has a tax deduction caused such a stir this week?

The SALT cap hasn’t been too popular with constituents in these high-tax states; they have been putting pressure on their lawmakers to make changes.

Trump initially expressed support for those changes, and many House GOP lawmakers from blue states ran on making changes when Republicans got back in power.

Now, House Republican lawmakers are in the middle of putting together a big spending and tax bill, and there was a push to get SALT changes in there. Those that ran on upping the SALT cap said, We’re trying to get reelected in the next year, we need a win to go back to our voters with.

The GOP leadership in the House set up a somewhat arbitrary deadline to get the bill passed from the House to the Senate by Memorial Day — that’s next week.

That puts lawmakers in a time crunch, but there’s also a numerical problem: the House GOP has very narrow margins. Depending on attendance, they can afford to lose roughly three votes on any one bill.

That gives the blue-state GOP lawmakers who want to see changes to SALT a lot of power. If you’re one of a small group, and you said, Hey, we’re holdouts, we’re not voting for this until you give us our SALT reform, you’re sinking Trump’s “big, beautiful bill.” And that’s what happened this week.

That small group of lawmakers got their way, right?

Yes. The final details could still change, but a deal was made to raise the cap.

Which set off other small groups of lawmakers who want their priorities fulfilled in the bill, and yesterday’s scramble by the White House to try to get everyone in line.

Right. Trump’s stance throughout this has been, stop whining. Don’t grandstand. It’s more important to get a deal done. So if you don’t get a SALT increase, tough luck. If they get their SALT increase, but you don’t get your thing, tough luck.

The Senate hasn’t even weighed in on the bill yet, so we’re a long way from getting changes to SALT enshrined in law. But at this point, what should we take away from the SALT saga?

SALT is inherently interesting because it’s a microcosm of the fragile political process in Congress at this time in which we often see parties with tiny minorities. Congressional leadership is more centralized than ever, but at the same time, small groups of people can really gum up the works.

It also shows how complex the Republican coalition is — the fight over SALT is really a battle between lawmakers from high-income states and those from lower-income states. We’ve seen pro-SALT lawmakers make the claim that their states’ tax base makes up a disproportionate amount of revenues, and that their constituents deserve a break because of that.

And smaller states or states with lower incomes might say, in response, we have our own needs, and we provide a lot, from farming to the numbers that power our GOP coalition.

I wouldn’t say that the fight over SALT is a fight for the soul of the Republican Party, but it’s definitely a factional fight for power.

And overall, it really shows how hard it is to actually legislate right now, in a divided Republican caucus, in a divided America.

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