The price range reconciliation act (H.R. 1)—previously named the “One Huge Lovely Invoice Act” or OBBBA—was signed into regulation on July 4, 2025. It cuts over a trillion {dollars} from Medicaid, Medicare, and the Inexpensive Care Act (ACA). Consequently, between 7.5 million and 10 million low earnings persons are projected to have their Medicaid protection taken away and 15 million individuals will develop into uninsured. A number of provisions within the regulation are particularly detrimental to older adults, individuals with disabilities, and their households and caregivers.
This explainer and implementation timeline, together with the corresponding detailed section-by-section abstract, determine essentially the most consequential well being and long-term care provisions of the regulation for low-income older adults. Justice in Growing older will monitor implementation of H.R. 1 and supply assets for advocates within the coming months.
Bureaucratic Boundaries to Medicaid Protection for Low-income Older Adults
The regulation provides work necessities, cuts retroactive protection, and provides copays, imposing administrative, monetary, and eligibility limitations that may block many older adults from Medicaid protection. Collectively, these measures create brutal roadblocks that may inevitably terminate entry to well being and long-term care people desperately want.
Work Necessities
Starting no later than January 1, 2027, requires adults ages 19-64 enrolled by way of the Medicaid enlargement or expansion-like waivers in Wisconsin and Georgia to finish and repeatedly report at the very least 80 hours per 30 days of qualifying actions comparable to paid employment, college, or volunteering. States should confirm compliance with the work necessities or exemptions utilizing present information sources accessible to the state, like payroll information, earlier than requiring people to submit documentation. States should confirm compliance with work necessities previous to enrollment and at the very least throughout eligibility redeterminations each six months, however can examine extra incessantly, which might result in protection loss because of procedural points like missed paperwork or delayed mail. States are additionally required to exempt sure teams together with some mother and father of minor youngsters as much as age 13, sure household caregivers, and people with disabilities, power circumstances, or who’re deemed “medically frail.” Sadly, these exemptions are narrowly outlined and fail to seize the realities going through Medicaid enrollees—together with many older adults–who’re unable to work. Incapacity-based exemptions additionally create an inconceivable predicament: individuals want medical documentation to “show” incapacity for an exemption, however are unable to afford medical care with out Medicaid.
Decreased Retroactive Protection Interval
Starting January 1, 2027, limits retroactive Medicaid protection to the month previous to the month of utility for enlargement enrollees, and two months prior for all different Medicaid teams. The present three-month retroactive interval ensures people experiencing medical emergencies can obtain care with loads of time to finish the onerous enrollment course of. Suppliers might additionally render providers understanding they are going to be reimbursed when Medicaid is authorised. These assurances at the moment are restricted as a result of shorter retroactive interval.
Extra Frequent Renewals
Starting January 1, 2027, requires states to redetermine eligibility each six months for the Medicaid enlargement inhabitants, as an alternative of each 12 months as at present required. The renewal course of may be very complicated and troublesome for a lot of Medicaid enrollees because of misplaced mail, confusion finishing renewal kinds, and issue accessing documentation to confirm eligibility. Rising renewals to each six months will result in eligible people having protection terminated because of these administrative challenges.
New Value Sharing
Starting October 1, 2028, requires states to impose some stage of cost-sharing on individuals enrolled in Medicaid enlargement with incomes over 100% of the Federal Poverty Degree (FPL) for well being care providers, excluding main care, psychological well being care, substance use dysfunction therapy, or providers offered by a federally certified well being middle, or behavioral well being or rural well being clinic. Medicaid enrollees at near-poverty ranges will doubtless delay medical care because of these extra prices, worsening well being outcomes in the long term. Requiring price sharing for sure Medicaid enrollees additionally will increase the danger that older adults and folks with disabilities might be improperly billed by suppliers who could not perceive who’s topic to new price sharing.
Moratorium on Streamlining Eligibility and Enrollment Rule
Efficient instantly, prevents implementation or enforcement of sure provisions of the Streamlining Eligibility and Enrollment Rule for ten years. The rule offered protections to forestall improper terminations by making enrollment and renewals less complicated by way of improved digital information matching, standardized notices, and lowered paperwork for all Medicaid enrollees.
Decreased Entry to Medicaid Lengthy-Time period Providers and Helps (LTSS)
The regulation contains a number of provisions that strip nursing house residents of key protections and curb entry to Medicaid Dwelling- and Group-Primarily based Providers (HCBS) by tightening eligibility necessities for belongings and lowering funding for this system. When older adults lose reliable, high quality long-term care, their power illnesses worsen, sending them to hospitals and leading to untimely dying. Older adults develop into saddled with hovering out-of-pocket bills and stripped of the important helps that maintain their independence.
Restrictions on State Medicaid Funding Jeopardize HCBS
Efficient instantly, prohibits all states from creating new or increased supplier taxes used to fund their share of Medicaid prices regardless of rising well being care prices and long-term providers and helps (LTSS) wants. As well as, allowable supplier taxes for Medicaid enlargement states might be lower from a most of 6% to three.5% by 2032. (Taxes on nursing services and intermediate care services are excluded from the decrease cap however are topic to the freeze.) The regulation additionally limits state-directed funds in Medicaid managed care, additional proscribing states’ skill to fund Medicaid. When states have lowered funding, they may discover financial savings by reducing non-obligatory packages like HCBS, which account for over half of all non-obligatory Medicaid spending. Older adults and folks with disabilities of all ages depend on HCBS to obtain essential providers of their properties. Slicing HCBS will pressure household caregivers and pressure people into nursing properties and different establishments as their solely choice for long-term care. As well as, states could lower supplier fee charges, which can worsen workforce crises that already restrict entry to high quality LTSS.
Moratorium on Nursing Dwelling Minimal Staffing Rule
Efficient instantly, prevents implementation of the nursing house minimal staffing rule for ten years. The rule required a minimal variety of nursing care hours for every resident and required a registered nurse on website 24/7. Staffing ranges are strongly correlated with improved well being and security for essentially the most high-needs seniors. Delaying this rule permits power understaffing for essentially the most susceptible residents to proceed, rising the danger of neglect, preventable accidents, and even deaths.
Decreased Dwelling Fairness Exclusion
Efficient January 1, 2028, restricts and freezes the utmost quantity of house fairness that’s excluded when figuring out eligibility for Medicaid LTSS at $1 million. Twelve states at present have house fairness limits above $1 million, which means some individuals in these states might lose eligibility or their house when this cover takes impact. Many low-income older adults are cash-poor, house-rich, which means they’ve little or no earnings or financial savings exterior of their properties, which they doubtless bought a long time earlier. Permitting states to set a better home-equity restrict that will increase with inflation helps account for will increase in house values and helps many of those people preserve their house and entry to wanted LTSS. As house costs have surged—and can proceed to rise—freezing the house fairness restrict at a stage beneath the present most creates a merciless dilemma the place seniors should both promote their house or lose entry to important long-term care and danger critical well being decline.
Protection Losses in Medicaid and Past
Along with the huge cuts to Medicaid, H.R. 1 additionally strips well being protection for hundreds of thousands of others, together with low-income seniors dually enrolled in Medicare and Medicaid, lawfully current immigrants, and ACA Market enrollees. For a lot of low-income older adults, the ramifications of gaining access to these packages terminated means they lose monetary assist that helps them afford the prices of different primary wants. Dropping well being protection additionally results in delays in therapy, permitting power circumstances to worsen and leading to extra expensive care sooner or later. As well as, hospitals will face a surge in uncompensated care as extra individuals can now not afford preventative care or early interventions. Suppliers, significantly these in rural and high-poverty areas, danger closing departments or complete clinics and hospitals, undermining healthcare entry for the complete group, together with older adults with Medicare.
Moratorium on Streamlining Medicare Financial savings Program Eligibility and Enrollment
Efficient instantly, blocks implementation of some provisions of the Streamlining Eligibility and Enrollment Rule, which aimed to assist low-income Medicare enrollees entry help with Medicare premiums, deductibles, and co-pays by way of the Medicare Financial savings Packages (MSPs). The rule required states to make use of present information sources to determine and streamline enrollment in MSPs, simplify documentation necessities, and forestall gaps in protection between Medicare and Medicaid. Thousands and thousands of low-income seniors might be prevented from enrolling or be terminated from MSPs and face steep Medicare prices, forcing many to skip or delay medical care and inflicting monetary pressure.
Decreased Federal Funding
Cuts federal funding for Medicaid by $990 billion and shifts different prices to states. States should stability their budgets and might be pressured to fill the hole in federal funding by reducing Medicaid advantages, eligibility, and/or supplier fee charges. Along with anticipated cuts to HCBS, states are additionally prone to lower different non-obligatory advantages like dental, imaginative and prescient, and listening to. As a result of Medicare doesn’t cowl these advantages, extra low-income older adults are going to go with out entry to this primary well being care, exacerbating present well being disparities. States might additionally roll again earnings and asset eligibility expansions for his or her aged & disabled Medicaid packages and Medicare Financial savings Packages. If this occurs, extra older adults with earnings above 100% FPL will fall off the eligibility cliff once they develop into eligible for Medicare.
Eligibility Restrictions for Lawfully Current Immigrants
Efficient January 1, 2026, limits eligibility for Medicare, Medicaid, and Market tax credit to 3 particular classes of non-citizens: authorized everlasting residents (inexperienced card holders), Cuban/Haitian household reunification program entrants, and Residents of the Freely Related States (Micronesia, the Marshall Islands, and Palau). Thousands and thousands of lawfully current immigrants, together with those that’ve dutifully paid Medicare and different taxes for years, won’t have entry to the well being protection they paid into. Many who’ve their Medicare terminated will doubtless develop into uninsured as a result of they will be unable to afford Market protection with out premium tax credit. Older immigrants who’re nonetheless eligible for protection could also be deterred from signing up altogether as a result of worry and confusion round these arbitrary eligibility guidelines, fueling a chilling impact that worsens well being outcomes and deepens disparities. States may also be penalized with cuts to their federal reimbursements for offering restricted care to immigrants below Emergency Medicaid.
Expiration of Market Tax Credit
The regulation permits enhanced ACA Market tax credit to sundown on the finish of 2025, eradicating the monetary lifeline that has saved protection reasonably priced for hundreds of thousands of low-income older adults ages 50 to 64 who usually are not eligible for Medicaid. With out these tax credit, premiums will climb sharply, forcing many enrollees to both pay dramatically increased prices or go with out protection. Greater than 4 million Market enrollees will develop into uninsured if the improved tax credit expire. That is particularly dangerous for older adults who’ve a lot increased premiums than youthful adults and can both pay considerably extra for a similar protection or be pressured to terminate protection altogether. One other million enrollees will lose medical insurance because of new rules that restrict enrollment and improve cost-sharing in Market plans.
Conclusion
H.R. 1 dismantles vital protections and funding streams that numerous older adults, individuals with disabilities, lawfully current immigrants, and their caregivers depend on, driving up prices and delaying care till crises come up. By stripping away eligibility safeguards, freezing advantages, and reducing supplier assist, this regulation threatens hospital viability—particularly in rural and high-poverty areas—and deepens well being disparities throughout complete communities.
Justice in Growing older might be offering extra evaluation and advocacy instruments to assist mitigate the hurt of H.R. 1 on the nationwide, state and particular person shopper stage. See Justice in Growing older’s Medicaid Protection Sources for all our assets on H.R. 1.
