Is the Affordable Care Act on the Chopping Block? What the One Big Beautiful Bill Act Tells Us.
It’s been weeks of headline-grabbing debate over Medicaid work requirements, and the “One Big Beautiful Bill Act” remains in the Senate as they deliberate over several health care provisions. While the Medicaid provisions sparked most of the initial buzz and my focus (and for good reason, the work requirements alone could impact coverage for more than 10 million people), it’s the quieter shifts to the Affordable Care Act (ACA) that may end up making just as big an impact.
So Where Does the ACA Go From Here?
Let’s start with enrollment, the foundation of how the ACA expands access. Right now, if you qualify for subsidized coverage and don’t update your income information, the system assumes you’re still eligible and reenrolls you.1 Under this bill, that automatic safety net disappears. Everyone would need to resubmit income documentation each year or risk losing their plan. That may sound manageable in theory, but in practice, may open the door to confusion, missed deadlines, and/or gaps in coverage. People juggling multiple jobs, caregiving responsibilities, or limited internet access may be impacted the most.2
This change isn’t happening in a vacuum. The bill also shortens the Open Enrollment Period by a full month. That means fewer days to review options, seek help, and make decisions.2 Does limiting the window really streamline things?
Now layer on the financial angle. In preliminary Congressional Budget Office analyses, these enrollment-related provisions, alongside the Medicaid cuts, could potentially push nearly 14 million people off coverage by 2034.3 That includes millions who would otherwise be covered by ACA marketplace plans. It's part of a broader effort to reduce federal spending. The bill trims roughly $880 billion in health coverage costs over the next decade.3
Supporters of the bill point to those savings as a necessary course correction, a chance to rein in federal health spending and reduce long-term budgetary pressure. With Medicare’s trust fund approaching insolvency and national debt at historic highs, this kind of fiscal restraint may appeal to policymakers looking to stabilize the broader system. If you're focused on deficit reduction, reining in entitlement spending is a responsible step.
But what’s the real cost of those savings? Critics of the bill point to families relying on subsidies to make insurance affordable, where the answer isn’t just dollars and cents. It’s missed doctor appointments, unfilled prescriptions, and delayed diagnoses. It's the kind of ripple effect that health economists have tracked for years, but that rarely gets factored into the bottom line.
These are the questions Senate lawmakers will be facing in the coming weeks as they face the July 4 deadline.4 And they’re the same ones we should all be asking, whether you're in state government, a provider organization, or part of a market access team trying to forecast patient access in 2026.
So, does the One Big Beautiful Bill Act repeal the ACA? Technically, no. The law is still on the books. But functionally? It draws sharp new lines around who can access coverage and how. By dialing back enrollment safeguards and federal support, the bill narrows the path to insurance—not through direct repeal, but by erosion. I’m no geologist, but this kind of erosion rarely happens all at once. It could take years to settle in—or, under the right pressure, it could come down in a landslide.
Next week, I’ll dig into how states might respond if the bill becomes law. What tools will they have to protect enrollment? Will they try to plug the gaps, or will we see even more fragmentation in how Americans get coverage?
Join me every Wednesday as I highlight key court decisions, review notable health policies, and analyze what’s behind the bill in health care.
References
1. Keep or change your insurance plan. HealthCare.gov. Accessed June 3, 2025. https://www.healthcare.gov/keep-or-change-plan/automatically-enrolled/
2. Sullivan P. How the GOP megabill may roll back the Affordable Care Act. Axios. May 30, 2025. Accessed June 3, 2025. https://www.axios.com/2025/05/30/gop-megabill-affordable-care-act
3. Congressional Budget Office. Preliminary analysis of the distributional effects of the One Big Beautiful Bill Act. May 20, 2025. Accessed June 3, 2025. https://www.cbo.gov/publication/61422
4. Carney J. ‘A ton of tradeoffs’: Thune acts fast to cut deals and move Trump’s megabill. Politico. June 4, 2025. Accessed June 4, 2025. https://www.politico.com/news/2025/06/04/john-thune-interview-big-beautiful-bill-00384324
