President Trump’s sweeping tax and spending package, signed into law on July 4th, 2025, has sent shockwaves through the healthcare system. The legislation, which slashes government healthcare spending by over US$1 trillion over the next decade, is projected to leave millions of Americans without health insurance by 2034. Initial estimates from the Congressional Budget Office (CBO) predicted around 12 million people would lose coverage. However, more recent analyses suggest the number could be significantly higher, potentially exceeding 17 million.
This alarming figure stems from a combination of factors. The expiration of Affordable Care Act (ACA) marketplace subsidies at the end of 2025 is a major contributor, threatening to leave at least 5 million Americans without coverage. With little Republican support for renewal, the outlook is grim for those relying on these subsidies. Further compounding the problem are new regulations introduced earlier in the year by the Trump administration, which are expected to drive up the number of those losing ACA marketplace coverage even further.
The impact on Medicaid is equally devastating. The introduction of nationwide work requirements by 2027 is estimated to displace 5 million individuals currently covered by the program. These requirements, often targeting those with slightly higher incomes within the Medicaid system, are likely to prove particularly challenging for individuals to meet, leading to a significant loss of benefits due to administrative hurdles rather than genuine inability to work. Additional paperwork burdens and new citizenship/immigration requirements are projected to push another 3.4 million people off Medicaid.
Medicaid recipients who remain enrolled will also face new copayments of up to $35 per visit, potentially deterring them from seeking necessary care. State-level financial constraints, due to limits on taxes charged to medical providers, could further reduce access to care as states struggle to maintain Medicaid funding. This leaves millions of low-income Americans, particularly people of color and non-English speakers, vulnerable to losing their healthcare safety net with few affordable alternatives.
The ACA marketplace is also facing a crisis. The new law makes it harder to purchase insurance and qualify for subsidies, impacting over 24 million Americans currently covered through these plans. Coupled with the CBO’s projection of nearly 1 million losing coverage due to the Trump administration’s prior regulations and the impending expiration of enhanced subsidies (which could lead to a 75% premium increase), the future of the ACA marketplace looks precarious. The potential withdrawal of major insurers due to market instability could further limit choices and increase premiums, leaving some counties without any ACA plans available.
The consequences of this widespread loss of insurance coverage are severe. Delayed diagnoses due to lack of access to care will lead to worsened health outcomes and increased mortality. The mounting medical debt associated with uninsured care will place a significant burden on individuals, families, and the healthcare system as a whole. Rural hospitals, many already struggling financially, face an increased risk of closure, potentially exacerbating access issues in underserved communities. Children’s hospitals and those in low-income urban areas, heavily reliant on Medicaid funding, will also be severely impacted.
The allocated $50 billion in funding for rural hospitals over 10 years is far from enough to offset the projected $155 billion in losses due to Medicaid cuts, and restrictive conditions attached to the funding further limit its impact. Further healthcare policy changes are anticipated, potentially including harsher provisions than those already in place. The possibility of rolling back the ACA’s Medicaid expansion and potential cuts to Medicare further threaten the health and well-being of millions of Americans. The future of healthcare access in the United States hangs precariously in the balance.
