For Katy Zander and her family, Medicaid is a lifeline. 

Zander lives in a small town in west central Michigan with her 60-year-old husband, her 14-year-old grandson with severe autism, and her 13-year-old son. Her own chronic illnesses prevent her from having a traditional job, but she is a full-time caregiver for her grandson. They are all on Medicaid. 

But with President Donald Trump’s budget bill imposing historic cuts to Medicaid totaling almost $1 trillion—along with cuts to the Affordable Care Act (ACA) and a $186 billion reduction of the Supplemental Nutrition Assistance Program (SNAP)—families like Zander’s are worried for their futures. Estimates have predicted that some 10 million people could lose their health insurance by 2034 because of the cuts. That’s not to mention the 5.1 million more who could lose insurance due to the probable end of ACA tax credits that subsidize high marketplace premiums.

“If we were to lose Medicaid, it would devastate our family,” Zander said in an email. “Medications would be stopped. The medications my husband takes keep him alive and breathing. The medication I take keeps me from developing thyroid cancer and having a heart attack.”

The Medicaid cuts have several components, but their most significant impact will come from the addition of work requirements that require Medicaid recipients to prove they are working, volunteering, or in school for at least 80 hours per month. The rule is set to take effect Jan. 1, 2027. Though it includes exceptions for disabled people, caregivers of kids younger than 13, and some other protected groups, proving eligibility will mean more red tape and bureaucratic hurdles to remaining insured, effectively kicking many off. The new rules also require the government to re-certify Medicaid eligibility every six months rather than once a year, likely leading to significant coverage gaps. The bill also reverses improvements made under the Biden administration to streamline enrollment.

Numerous studies show that work requirements are ineffective. Plus, the vast majority of Medicaid recipients already do work, according to the health policy think tank KFF: 64% in formal work settings and 12% work as caregivers, with 7% in school. An estimated 10% do not work due to disability.

In addition, Trump’s bill imposes further restrictions for immigrants trying to qualify for Medicaid, barring many—including most refugees—from qualifying unless they have a green card. It also bars some funding for reproductive health care and gender-affirming care, and will reduce funding for substance use disorder treatment. 

Though Zander should technically qualify for an exemption from work requirements due to her chronic illnesses and responsibilities as a caregiver, she is still concerned she’ll have difficulty proving it. Nothing “on the surface prevents me from working,” she said. But “the care of my grandson makes it impossible to work outside of the home.”

Zander is among the nearly 71 million people who rely on Medicaid for health insurance. The cuts will overwhelmingly impact people with disabilities, Black, brown, and Indigenous communities, as well as older adults and people living in rural areas—groups that disproportionately rely on Medicaid for lifesaving health care.

With the health care cuts, the Trump administration is “fleecing the American people,” Zander said.

As Dom Kelly, the CEO of the disability advocacy organization New Disabled South, told Prism, “It’s shameful to me that we live in the richest country in the world, yet we are cutting nearly a trillion dollars in lifesaving and life-sustaining health care for people who need it most.” 

The new requirements could also lead to significant interruptions in coverage, or people being disenrolled by mistake, according to Dr. Betty Kolod, a primary care physician who works with majority Medicaid patients. She also chairs the board of the New York Metro chapter of Physicians for a National Health Program, an organization that advocates for a universal, comprehensive, single-payer national health program. Accidental disenrollments could force patients to delay care, leading to preventable, debilitating complications. 

“My fear is that people who have legitimate reasons for not being able to work, or people who even are working, are not going to be able to demonstrate that they are working, and they’re going to see interruptions in their Medicaid coverage as a result,” Kolod said.

Zander lives in Michigan, one of the 41 states that expanded Medicaid eligibility by increasing its income cap as part of the ACA of 2010. Trump’s bill specifically targets Medicaid expansion states, making it harder for them to fund their programs by restricting provider and hospital tax rates. Penalizing expansion states could force those states to reduce their Medicaid programs, leading to significantly decreased coverage.

“Of course [Republicans] are going to penalize states that have expanded Medicaid,” Kelly said. “Medicaid expansion has become a political issue. It’s become an attack on the Obama administration.”

As of June 2024, Medicaid expansion has helped over 20 million people gain insurance coverage. Dr. Soumya Rangarajan is a geriatrician and assistant professor at a large academic hospital in Michigan, which expanded Medicaid eligibility. She told Prism that the U.S. is regressing in health care availability. While the ACA and Medicaid expansion helped get tens of millions insured, many of those people are now in danger of losing coverage. 

“We’re probably going to reverse right back to where we were in the early 2000s before the ACA,” Rangarajan said.

The Medicaid cuts come just a few years after nearly 27 million people nationwide lost their insurance due to resumed eligibility checks after the Biden administration declared the COVID-19 public health emergency over in May 2023. 

Preventable deaths  

According to May’s polling of more than 2,500 adults in the U.S., a majority of them worry about the impact of Trump’s cuts.

“I’m concerned that we’re reaching the point of an implosion in our health care system,” Rangarajan said. “I think the Big Beautiful Bill … may be the straw that breaks the camel’s back. I think we’re going to start seeing people die en masse of preventable deaths because … they don’t have access to medical care.” 

Although the work requirements don’t take effect until after the midterm elections—likely part of the GOP’s strategy—Rangarajan said that hospitals like hers are already feeling the impact because they budget several years in advance and now need to plan for reduced funding. She also pointed out that medical facilities are already becoming more expensive to run due to the Trump administration’s tariffs on certain medical supplies. 

Medicaid and SNAP beneficiaries are already struggling. Many already experience food insecurity, even with assistance, according to KFF. While SNAP runs differently than Medicaid in that it’s entirely federally funded and already has work requirements attached to it, Trump’s new rules expand existing work requirements for adults up to age 64. Previously, the work requirements only went up to age 54. On average, this will reduce SNAP participation by about 2.4 million people in an average month between 2025 and 2034. The new rules also make immigrants, save for green card holders and citizens, ineligible, according to Congressional Budget Office estimates. 

But the most significant shift is that, starting in fiscal year 2028, the bill forces states to take on a portion of funding, calculated according to their administrative error rates. As a result, all but seven states would have to contribute 5% to 15% of their SNAP budget. Oddly, the bill includes a provision that would allow states with exceptionally high error rates of 20% or more to delay their contribution until 2029.

Beginning fiscal year 2027, Trump’s law also shifts administrative overhead costs to states from 25% to 50%. According to the Urban Institute, these requirements will force states to reduce SNAP benefits, which are already inadequate, while also imposing stricter, burdensome eligibility and recertification requirements. Some states may be forced to end their SNAP programs entirely. 

Taken together, states will lose federal funding for Medicaid, while paying more for SNAP, meaning less funds overall to make up for the Medicaid losses. As health policy experts Alison Barkoff and Leighton Ku wrote in Health Affairs, “The SNAP proposals would not only directly harm the millions of older adults and disabled people who rely on the program; they also would make deep cuts to Medicaid even more likely.” Notably, people who receive SNAP spend about 25% less on medical care than nonparticipants. 

The health care system is in crisis, experts, advocates, and patients told Prism—and the pandemic only exacerbated its myriad problems. As Rangarajan put it, “We’re already bursting at the seams.”

How will the cuts affect those in most need of services?

The sharp cuts to public benefits in Trump’s bill will negatively impact the communities that are already struggling most. People with disabilities will be among the hardest hit. While many disabled people should qualify for exemptions to work requirements, proving eligibility will involve many bureaucratic hurdles, particularly due to more frequent recertification requirements. Also worth noting are the stigma, discrimination, and access issues disabled people already regularly face when attempting to obtain benefits. 

“The work requirements themselves are just inherently ableist,” Kelly said. “We know that there are plenty of people who are considered disabled who might not qualify for Medicaid for a number of reasons, but still are impacted, and may not be able to afford health care otherwise.”

Kelly also noted that work requirements do not actually increase employment levels. Both Arkansas and Georgia attempted to impose work requirements for Medicaid in recent years, and there has been no impact on employment levels. Tens of thousands lost their Medicaid. “It was an abysmal failure,” Kelly said. 

Seth Robert Hill, who lives in southern Missouri, suffers from diabetes, fibromyalgia, and other debilitating health conditions. After college, he said he worked an office job for a few years, but his pain and other symptoms made it impossible to maintain employment. 

“It’s very hard to explain this pain,” he said. “It feels like a lightning bolt. … It would feel like somebody was stabbing me in the teeth.” While working, he said he would “curl up in a ball and cry in the bathroom every day. It was terrible.”

He now relies on Medicaid for his health care needs. He is afraid he could lose those benefits due to new work requirements. It feels to him like the government “wants disabled people to suffer,” he said. “The cruelty is the point.”

Hill also receives a small amount of SNAP benefits per month, but he told Prism these funds wouldn’t be nearly sufficient if his parents weren’t helping him pay for food.

Once he realized he couldn’t work, Hill faced an uphill battle qualifying for Social Security Disability Assistance (SSDI), monthly payments that disabled people, unable to participate in the traditional labor market, can use to pay for their necessities. The process made clear to him how hostile society is to people who cannot work. “The system is so rigid,” he said. “You either work or you die.”

Hill was rejected for SSDI three times in three years, until his family hired a private lawyer to help with the process. He was ultimately successful in obtaining the benefits he needed. “It’s saved my family,” he said.

With the rapidly increasing number of disabled people in this country since the COVID-19 pandemic, more people will need Medicaid as funding for it dwindles. “This country is not prepared,” Kelly said.

Trump’s bill harms those already lacking access 

Medicaid covers a majority of disabled children in the U.S. About half of the 13.9 million children with special health care needs rely on the program for insurance and care, including some school-based services, according to The 19th.

Cynthia Adinig, a Virginia-based mom and health care advocate, has severe long COVID and has also faced barriers in qualifying for needed benefits. Though disabled people are supposed to be exempt from SNAP work requirements, Adinig said she was denied food assistance because she couldn’t prove her disability. She’s not the only one: Research shows that imposing these kinds of requirements makes disabled people less likely to apply for SNAP benefits. As a result, Adinig has been forced to ration food and medications for herself and her son. 

“It really is an impossible system meant to deny those of us from getting care,” she said via email.

Food insecurity already disproportionately impacts disabled communities. According to the National Women’s Law Center, in 2023, 24% of people with disabilities didn’t have enough food, compared with 9% of non-disabled people. And nearly a third of disabled Black women like Adinig were going hungry.

More broadly, disabled people and advocates are terrified that when Medicaid programs are forced to make cuts at the state level, home-based care services (HBCS) could be first on the chopping block, explained Kelly. These programs allow disabled people to pay caregivers at home instead of being forced into an institution or nursing home. Notably, private insurers usually don’t cover in-home care.

These critical programs allow disabled people to remain a part of the community, be more independent, and live with dignity. Critically, they also pay for caregivers, who in some cases are family members. Without this funding, caregivers could also soon find themselves without jobs, despite massive demand.

The funding cuts will also impact the 13 million disabled older adults who are dually eligible for both Medicare and Medicaid. Under Trump’s new bill, some 1.3 million of that demographic could lose their Medicaid and therefore their eligibility for HBCS services, as well as daytime care programs many older adults benefit from, explained Rangarajan. Studies have shown that most adults over 50 want to remain at home as they age rather than move into a long-term care facility.

Staying at home is also much more cost-effective than nursing homes—and Trump’s bill does create a new category for HBCS waivers. But the funding for the waivers is wildly insufficient, covering costs for only 27 people per state, according to the Center for American Progress. 

Medicaid cuts will also strain already struggling nursing homes. Medicaid pays for almost two-thirds of long-term care residents in nursing homes, a population that is disproportionately women and women of color, according to The 19th. In a move that can only be described as dangerous, Trump’s bill also blocks the implementation of staffing requirements in nursing homes, though staffing shortages are already known to increase injuries and deaths in these facilities. 

The administration’s war on immigrants could also have an impact here. “We’re very dependent on immigrants for elder care,” Rangarajan explained. “So with all of the immigration restrictions and the fact that they’re just deporting people … we don’t have enough [caregivers].” 

The Medicaid cuts themselves target immigrants, restricting Medicaid and SNAP to only green card holders and citizens. This excludes the majority of refugees and asylum-seekers. 

“People are still very afraid and asking a lot of questions about whether it’s safe” to apply for benefits, Celia Valdez told Prism in an email. Valdez is the director of outreach and education at Maternal and Child Health Access, a Los Angeles-based organization that works with mostly immigrants.

To make up for labor shortages caused by deportations, Trump’s agriculture secretary, Brooke Rollins, suggested that people at risk of losing Medicaid due to work requirements can simply work on farms.

With funding cuts for long-term care and caregivers, Kelly said more disabled people will become unhoused. “It’s just going to get worse … there’s no backup, there’s no other system to help people,” he said. Already, many disabled and elderly patients have nowhere to go and wind up in the emergency room, according to Rangarajan. 

Hospital closures will hit rural areas hard, where health care access is already a major problem, explained Rangarajan in Michigan, where these closures already present major problems. Rural populations already have higher poverty rates and less access to health care than their urban counterparts, and since 2005, nearly 200 rural hospitals have been forced to close. The lack of Medicaid funding will force even more closures, the doctor said. “When these smaller hospitals close, people have nowhere else to go,” Rangarajan told Prism. 

In an emergency, having to travel hours to get to the nearest hospital will result in care delays and even death. In addition, not all hospitals have the equipment required to make complex diagnoses, explained Rangarajan. Specialty care for pregnant people has been an issue, too, as a lack of funding has forced the closure of maternity wards in certain hospitals, especially in states that have enacted abortion bans. 

Remaining hospitals are already struggling with understaffing and long wait times. Hill, who lives in a rural part of southern Missouri, said during emergency room visits, he’s had to wait over 12 hours just to get checked in—and then another 12 to 18 hours in the ER waiting room before being seen.

To soften the impact on rural health care, Republicans added a $50 billion “Rural Health Transformation Fund” to Trump’s bill. However, the response is poorly designed and grossly inadequate. According to Mother Jones, the rural health fund won’t be able to offset the losses of the cuts, and oddly divvies up half of the funding to states equally, notwithstanding population size or relative need. 

Hospitals with majority-Medicaid patients—often disproportionately Black and brown—are “systematically underfunded,” Kolod said, because Medicaid reimburses health care providers at a lower rate than private insurance companies. Both Kolod and Rangarajan expressed concern that when a number of these Medicaid patients become uninsured, their care will be entirely uncompensated, making it difficult for health care facilities to operate and further increasing disparities. Uncompensated care is an even bigger issue in the south, where many states have not expanded Medicaid, said Kelly—and it will only get worse. 

As Aallyah Wright wrote for Truthout, “Black communities will be the hardest hit, and the lack of access could lead to death and chronic illnesses, and worsen economic disparities.”

SNAP cuts will also worsen disparities between Black and Latinx people, who already have higher rates of food insecurity than their white counterparts and have consistently faced undue stigma and negative stereotypes for using public benefits. 

This stigma makes some afraid even to access benefits. Though LGBTQIA+ people are more likely to participate in SNAP, according to the National Women’s Law Center, almost 20% of trans people surveyed reported that they have avoided signing up due to fear of discrimination.

Indigenous populations will also face unique issues due to the Medicaid cuts. 

Indigenous communities are exempted from work requirements and more frequent recertifications in the new bill, and while they are entitled to health care through the Indian Health Service, it is consistently underfunded. Historically, Medicaid fills the gap for 30% of American Indian and Alaska Natives, including 40% of children. But it’s unclear where that money will come from for a population that experiences “severe health disparities” and “a life expectancy of 64 years—the lowest of any demographic group in the U.S.,” wrote Jazmin Orozco Rodriguez for KFF Health News. 

It is hard to overstate the impact of Trump’s unprecedented cuts to Medicaid and SNAP on an already failing health care system. “We pay two to three times or more per capita and we’re receiving substandard health care, and it’s impossible for people to access the health care they need,” Kolod said. “Every other rich capitalist democracy in the world has universal health care.”

Yet instead of improving access, the administration is just exacerbating the problem, said Zander, the Michigan mom and grandmother whose family relies on Medicaid. “The answer from this administration is to just pay for less people, not to force the medical system to play fair,” she said.

Kolod hopes that with enough advocacy, states could find ways not to cut Medicaid. 

“It is possible to raise taxes or to move money from other programs to plug the hole in the budget,” she said. But this will be a challenge even in states like New York, where she practices.

In light of the government’s large-scale state abandonment of vulnerable people, Kelly emphasized the importance of mutual aid and care webs to mitigate the harm. “There are so many people that are really showing up to meet the moment, to build new things, to help people survive this, and that gives me a lot of hope,” he said.

According to health care providers who spoke to Prism, there’s still a slim possibility that Republicans could be persuaded to limit the cuts in their states as the midterms draw closer. As Rangarajan put it, “People are going to start recognizing when people are dying in their districts.”

Otherwise, Hill warned, “The health care system is going to completely collapse.”

Editorial Team:
Tina Vasquez, Lead Editor
Carolyn Copeland, Top Editor
Stephanie Harris, Copy Editor