The budget reconciliation act (H.R. 1)—formerly named the “One Big Beautiful Bill Act” or OBBBA—was signed into law on July 4, 2025. It cuts over a trillion dollars from Medicaid, Medicare, and the Affordable Care Act (ACA). As a result, between 7.5 million and 10 million low income people are projected to have their Medicaid coverage taken away and 15 million people will become uninsured. Several provisions in the law are especially detrimental to older adults, people with disabilities, and their families and caregivers.
This explainer and implementation timeline, along with the corresponding detailed section-by-section summary, identify the most consequential health and long-term care provisions of the law for low-income older adults. Justice in Aging will monitor implementation of H.R. 1 and provide resources for advocates in the coming months.
Bureaucratic Barriers to Medicaid Coverage for Low-income Older Adults
The law adds work requirements, cuts retroactive coverage, and adds copays, imposing administrative, financial, and eligibility barriers that will block many older adults from Medicaid coverage. Together, these measures create brutal roadblocks that will inevitably terminate access to health and long-term care individuals desperately need.
Work Requirements
Beginning no later than January 1, 2027, requires adults ages 19-64 enrolled through the Medicaid expansion or expansion-like waivers in Wisconsin and Georgia to complete and regularly report at least 80 hours per month of qualifying activities such as paid employment, school, or volunteering. States must verify compliance with the work requirements or exemptions using existing data sources available to the state, like payroll data, before requiring individuals to submit documentation. States must verify compliance with work requirements prior to enrollment and at least during eligibility redeterminations every six months, but can check more frequently, which can lead to coverage loss due to procedural issues like missed paperwork or delayed mail. States are also required to exempt certain groups including some parents of minor children up to age 13, certain family caregivers, and individuals with disabilities, chronic conditions, or who are deemed “medically frail.” Unfortunately, these exemptions are narrowly defined and fail to capture the realities facing Medicaid enrollees—including many older adults–who are unable to work. Disability-based exemptions also create an impossible predicament: people need medical documentation to “prove” disability for an exemption, but are unable to afford medical care without Medicaid.
Reduced Retroactive Coverage Period
Beginning January 1, 2027, limits retroactive Medicaid coverage to the month prior to the month of application for expansion enrollees, and two months prior for all other Medicaid groups. The current three-month retroactive period ensures individuals experiencing medical emergencies can receive care with plenty of time to complete the onerous enrollment process. Providers could also render services knowing they will be reimbursed when Medicaid is approved. These assurances are now limited due to the shorter retroactive period.
More Frequent Renewals
Beginning January 1, 2027, requires states to redetermine eligibility every six months for the Medicaid expansion population, instead of every 12 months as currently required. The renewal process is very complex and difficult for many Medicaid enrollees due to lost mail, confusion completing renewal forms, and difficulty accessing documentation to verify eligibility. Increasing renewals to every six months will lead to eligible individuals having coverage terminated due to these administrative challenges.
New Cost Sharing
Beginning October 1, 2028, requires states to impose some level of cost-sharing on people enrolled in Medicaid expansion with incomes over 100% of the Federal Poverty Level (FPL) for health care services, excluding primary care, mental health care, substance use disorder treatment, or services provided by a federally qualified health center, or behavioral health or rural health clinic. Medicaid enrollees at near-poverty levels will likely delay medical care due to these additional costs, worsening health outcomes in the long run. Requiring cost sharing for certain Medicaid enrollees also increases the risk that older adults and people with disabilities will be improperly billed by providers who may not understand who is subject to new cost sharing.
Moratorium on Streamlining Eligibility and Enrollment Rule
Effective immediately, prevents implementation or enforcement of certain provisions of the Streamlining Eligibility and Enrollment Rule for ten years. The rule provided protections to prevent improper terminations by making enrollment and renewals simpler through improved electronic data matching, standardized notices, and reduced paperwork for all Medicaid enrollees.
Reduced Access to Medicaid Long-Term Services and Supports (LTSS)
The law includes several provisions that strip nursing home residents of key protections and curb access to Medicaid Home- and Community-Based Services (HCBS) by tightening eligibility requirements for assets and reducing funding for the program. When older adults lose dependable, quality long-term care, their chronic ailments worsen, sending them to hospitals and resulting in premature death. Older adults become saddled with soaring out-of-pocket expenses and stripped of the essential supports that sustain their independence.
Restrictions on State Medicaid Funding Jeopardize HCBS
Effective immediately, prohibits all states from creating new or higher provider taxes used to fund their share of Medicaid costs despite rising health care costs and long-term services and supports (LTSS) needs. In addition, allowable provider taxes for Medicaid expansion states will be cut from a maximum of 6% to 3.5% by 2032. (Taxes on nursing facilities and intermediate care facilities are excluded from the lower cap but are subject to the freeze.) The law also limits state-directed payments in Medicaid managed care, further restricting states’ ability to fund Medicaid. When states have reduced funding, they will find savings by cutting optional programs like HCBS, which account for over half of all optional Medicaid spending. Older adults and people with disabilities of all ages rely on HCBS to receive crucial services in their homes. Cutting HCBS will strain family caregivers and force individuals into nursing homes and other institutions as their only option for long-term care. In addition, states may cut provider payment rates, which will worsen workforce crises that already limit access to quality LTSS.
Moratorium on Nursing Home Minimum Staffing Rule
Effective immediately, prevents implementation of the nursing home minimum staffing rule for ten years. The rule required a minimum number of nursing care hours for each resident and required a registered nurse on site 24/7. Staffing levels are strongly correlated with improved health and safety for the most high-needs seniors. Delaying this rule allows chronic understaffing for the most vulnerable residents to continue, increasing the risk of neglect, preventable injuries, and even deaths.
Reduced Home Equity Exclusion
Effective January 1, 2028, restricts and freezes the maximum amount of home equity that is excluded when determining eligibility for Medicaid LTSS at $1 million. Twelve states currently have home equity limits above $1 million, meaning some people in those states could lose eligibility or their home when this cap takes effect. Many low-income older adults are cash-poor, house-rich, meaning they have very little income or savings outside of their homes, which they likely purchased decades earlier. Allowing states to set a higher home-equity limit that increases with inflation helps account for increases in home values and helps many of these individuals keep their home and access to needed LTSS. As home prices have surged—and will continue to rise—freezing the home equity limit at a level below the current maximum creates a cruel dilemma where seniors must either sell their home or lose access to essential long-term care and risk serious health decline.
Coverage Losses in Medicaid and Beyond
In addition to the massive cuts to Medicaid, H.R. 1 also strips health coverage for millions of others, including low-income seniors dually enrolled in Medicare and Medicaid, lawfully present immigrants, and ACA Marketplace enrollees. For many low-income older adults, the ramifications of having access to these programs terminated means they lose financial support that helps them afford the costs of other basic needs. Losing health coverage also leads to delays in treatment, allowing chronic conditions to worsen and resulting in more costly care in the future. In addition, hospitals will face a surge in uncompensated care as more people can no longer afford preventative care or early interventions. Providers, particularly those in rural and high-poverty areas, risk closing departments or entire clinics and hospitals, undermining healthcare access for the entire community, including older adults with Medicare.
Moratorium on Streamlining Medicare Savings Program Eligibility and Enrollment
Effective immediately, blocks implementation of some provisions of the Streamlining Eligibility and Enrollment Rule, which aimed to help low-income Medicare enrollees access assistance with Medicare premiums, deductibles, and co-pays through the Medicare Savings Programs (MSPs). The rule required states to use existing data sources to identify and streamline enrollment in MSPs, simplify documentation requirements, and prevent gaps in coverage between Medicare and Medicaid. Millions of low-income seniors could be prevented from enrolling or be terminated from MSPs and face steep Medicare costs, forcing many to skip or delay medical care and causing financial strain.
Reduced Federal Funding
Cuts federal funding for Medicaid by $990 billion and shifts other costs to states. States must balance their budgets and will be forced to fill the gap in federal funding by cutting Medicaid benefits, eligibility, and/or provider payment rates. In addition to expected cuts to HCBS, states are also likely to cut other optional benefits like dental, vision, and hearing. Because Medicare does not cover these benefits, more low-income older adults are going to go without access to this basic health care, exacerbating existing health disparities. States could also roll back income and asset eligibility expansions for their aged & disabled Medicaid programs and Medicare Savings Programs. If this happens, more older adults with income above 100% FPL will fall off the eligibility cliff when they become eligible for Medicare.
Eligibility Restrictions for Lawfully Present Immigrants
Effective January 1, 2026, limits eligibility for Medicare, Medicaid, and Marketplace tax credits to three specific categories of non-citizens: legal permanent residents (green card holders), Cuban/Haitian family reunification program entrants, and Citizens of the Freely Associated States (Micronesia, the Marshall Islands, and Palau). Millions of lawfully present immigrants, including those who’ve dutifully paid Medicare and other taxes for years, will not have access to the health coverage they paid into. Many who have their Medicare terminated will likely become uninsured because they will not be able to afford Marketplace coverage without premium tax credits. Older immigrants who are still eligible for coverage may be deterred from signing up altogether due to the fear and confusion around these arbitrary eligibility rules, fueling a chilling effect that worsens health outcomes and deepens disparities. States will also be penalized with cuts to their federal reimbursements for providing limited care to immigrants under Emergency Medicaid.
Expiration of Marketplace Tax Credits
The law allows enhanced ACA Marketplace tax credits to sunset at the end of 2025, removing the financial lifeline that has kept coverage affordable for millions of low-income older adults ages 50 to 64 who are not eligible for Medicaid. Without these tax credits, premiums will climb sharply, forcing many enrollees to either pay dramatically higher costs or go without coverage. More than 4 million Marketplace enrollees will become uninsured if the enhanced tax credits expire. This is especially harmful for older adults who have much higher premiums than younger adults and will either pay significantly more for the same coverage or be forced to terminate coverage altogether. Another million enrollees will lose health insurance due to new regulations that limit enrollment and increase cost-sharing in Marketplace plans.
Download the PDF to see the H.R. 1 Implementation Timeline.
Conclusion
H.R. 1 dismantles critical protections and funding streams that countless older adults, people with disabilities, lawfully present immigrants, and their caregivers rely on, driving up costs and delaying care until crises arise. By stripping away eligibility safeguards, freezing benefits, and cutting provider support, this law threatens hospital viability—especially in rural and high-poverty areas—and deepens health disparities across entire communities.
Justice in Aging will be providing additional analysis and advocacy tools to help mitigate the harm of H.R. 1 at the national, state and individual client level. See Justice in Aging’s Medicaid Defense Resources for all our resources on H.R. 1.
