The One Big Beautiful Bill Act is an attempt to streamline the U.S. healthcare system by replacing a collection of programs with a single, integrated framework. By consolidating regulations, reimbursement rules, and coverage structures, the bill seeks to reduce inefficiency, expand access, and promote fairness. Advocates hail it as the most consequential reform since the Affordable Care Act (ACA), while critics warn of new difficulties for patients, providers, and policymakers.
The ACA demonstrated that large-scale reform can produce tangible health benefits. After its passage, research showed that survival improved among patients with liver disease, and racial disparities in treatment access narrowed (1). These outcomes demonstrate how expanding coverage can lead to improvements in survival and reductions in disparities.
Under the ACA, Medicaid expansion was associated with lower mortality after congenital heart surgery and earlier cancer diagnoses, such as uterine and lung cancers (2). Preventive care also advanced, with more women starting HIV pre-exposure prophylaxis once coverage became available (3). Strategies to standardize Medicaid eligibility nationwide could extend these gains to states that resisted expansion, thereby narrowing long-standing geographic disparities. However, the One Big Beautiful Bill cuts federal support for Medicaid and reduces coverage through changes in eligibility requirements (4).
Medicare risk adjustment models have historically reinforced unequal reimbursement patterns. Recent studies show that redesigned algorithms can better promote fairness and reduce disparities among patient groups (5). Integrating these changes into a national framework could establish equitable reimbursement as a consistent standard rather than a temporary solution. Payment reform tied to telehealth offers another opportunity. The pandemic proved that virtual visits are a lifeline, not just a convenience, for rural and underserved patients. These are critical areas where healthcare reform could improve the health of Americans nationwide. However, opponents of the bill point out that it reduces Medicare support for vulnerable populations, such as low-income people and non-citizens (4).
Previous state-led reforms in long-term care have demonstrated that even well-designed policies can falter during implementation, creating gaps between legislative intent and patient experience (6). The One Big Beautiful Bill could encounter challenges on a larger scale, potentially generating new bureaucracy rather than reducing it. While greater federal negotiating power could lower costs for essential drugs like insulin or hepatitis C antivirals, centralized cost controls could slow access to high-cost, innovative therapies. Smaller and rural hospitals could also be at a disadvantage if uniform payment models favor larger systems, raising the prospect of consolidation and fewer choices for patients in vulnerable regions.
The One Big Beautiful Bill presents both promise and peril for U.S. healthcare. While it could promote fairness in reimbursement and decrease drug costs, it could also lead to higher healthcare costs as insurance coverage declines and disparities persist.
References
- Walker TL, Aridi TG, Iyengar M, et al. The Affordable Care Act Improves Access, Survival, and Racial Disparities of Patients With Liver Disease: A Systematic Review. Clin Gastroenterol Hepatol. Published online July 7, 2025. doi:10.1016/j.cgh.2025.04.032
- Ross FJ, Tjoeng YL, Chan T, Tan JM, Howard W, Jimenez N. The Impact of Medicaid Expansion on Congenital Heart Surgery Outcomes: Data From the Society of Thoracic Surgeons Database. Anesth Analg. 2025;140(5):1195-1204. doi:10.1213/ANE.0000000000007319
- Allen DC, Rabionet SE, Dale SK, Popovici I. What Is the Effect of Medicaid Expansions on Preexposure Prophylaxis for HIV Prevention Use among Women?. AIDS Behav. Published online July 28, 2025. doi:10.1007/s10461-025-04828-2
- Rosen A. “How New Federal Legislation Will Affect Health Care Costs and Access for Americans” (July 30, 2025). Johns Hopkins Bloomberg School of Public Health. https://publichealth.jhu.edu/2025/the-changes-coming-to-the-aca-medicaid-and-medicare
- Reitsma MB, McGuire TG, Rose S. Algorithms to Improve Fairness in Medicare Risk Adjustment. JAMA Health Forum. 2025;6(8):e252640. Published 2025 Aug 1. doi:10.1001/jamahealthforum.2025.2640
- Naylor MD, Kurtzman ET, Miller EA, Nadash P, Fitzgerald P. An Assessment of State-Led Reform of Long-Term Services and Supports. J Health Polit Policy Law. 2015;40(3):531-574. doi:10.1215/03616878-2888460