Tens of billions of dollars — that’s how much New York is slated to lose in Medicaid funding under the version of President Trump’s “big, beautiful bill” that the Senate and the House passed. It’s the largest cut to American health care in U.S. history.
In what many call the “Big Ugly Bill,” an estimated 1.5 million New Yorkers could lose their health care coverage. This includes not just Medicaid recipients but also people enrolled in the Essential Plan, which offers low-cost coverage to New Yorkers who don’t qualify for Medicaid but still need affordable insurance. Research has long shown when people lose coverage, they’re more likely to be sicker and die earlier.
These steep cuts could also force hospitals to consider service reductions, layoffs, and even closures. Unsurprisingly, safety net hospitals and clinics that serve low-income and other vulnerable New Yorkers are most at risk.
What happened to the bill?
In the Senate, the bill’s fate was decided in a 51-50 vote on Tuesday, with all Democrats and three Republicans opposed. Its passage came after more than 24 hours of negotiations and changes to the bill. One change: this version contains deeper Medicaid cuts than the previous House bill.
“It is astonishing to me that any member from the New York delegation would vote for this bill,” said Elisabeth Benjamin, vice president of health initiatives at the Community Service Society of New York (CSSNY), citing the vast swaths of New Yorkers who would lose access to health insurance and the billions it would cost local hospitals. “And it will basically shoot a $13 billion hole in our state budget … all for what? [So] we get tax cuts for wealthy people?”
The House convened Wednesday morning to negotiate and debate this bill, and Republicans wielded an 11th-hour effort through Thursday to secure the votes needed to pass in the House.
What’s next?
The bill is heading to the president’s desk to be signed into law. Trump wants to sign it by Independence Day.
Who would be most impacted?
Low-wage workers such as retail, restaurant and construction workers and home health aides — those who can’t get job-based health insurance coverage — will be some of the most affected New Yorkers, according to Benjamin.
New York is the second most expensive place to get health insurance in the country, so employers often won’t offer it, she explains.
“[The bill’s supporters’] idea is, ‘well, too bad, since the employer doesn’t offer it, they’re just blank out of luck,’” Benjamin said. “And that’s just a really unethical and immoral way to run a country’s health care. It’s not like the federal government is supporting people buying leather counter couch couches and luxury cars. This is health care we’re talking about.”
Immigrants who are legally in the U.S. would no longer be eligible for either Medicaid or Affordable Care Act coverage. Contrary to popular misconception, undocumented immigrants are not eligible for Medicaid coverage.
And if these immigrants are pushed out of the health care system, insurance premiums for all New Yorkers could rise by 38%, Benjamin explains. After all, immigrants tend to be healthier and help balance overall health care costs.
On top of that, since New York State opted to support providing coverage for seniors, the elderly and undocumented immigrants, we’ll lose some of our federal matching funds, according to Benjamin.
New work requirements will also force more red tape on Medicaid beneficiaries — many of whom have jobs — to prove their eligibility. That means more time (and money, if you need to miss work).
Unpacking cuts to Medicaid funding in the bill
To further unpack the consequences of these possible rollbacks — and what else, if anything, we can do — we also spoke to Sarah Miller, a health economist whose research has helped shape the national understanding of Medicaid’s impact. Miller, an associate professor at the Ross School of Business at the University of Michigan, studies how Medicaid expansions improve health and access to medical care. The following are edited excerpts from the interview:
Epicenter NYC: How would proposed Medicaid cuts reduce enrollment?
Sarah Miller: It largely comes down to increasing the paperwork burden. Efforts to streamline enrollment would be rolled back. Then there’s the introduction of work requirements — 80 hours per month for non-elderly adults, with some exceptions.
But most Medicaid recipients already work — 64%, in fact. Those who don’t are often in school, caregiving, or have disabilities. Only 8% are retired, between jobs, or cite other reasons. The issue isn’t employment; it’s the added administrative burden. States might require monthly proof of work. In Arkansas, when they implemented such a requirement in 2018, 18,000 people lost coverage. Research found no increase in employment, only higher uninsured rates.
Epicenter NYC: And that coverage loss was mainly due to paperwork burdens, not actual ineligibility?
Sarah Miller: Exactly. The idealized outcome is that work requirements push people into jobs and greater self-sufficiency. But in Arkansas, people didn’t work more — they just lost coverage.
Epicenter NYC: For those with disabilities, would the exemption definitions be expansive, like including mental health diagnoses?
Sarah Miller: It depends on how states implement it. Federal guidelines often leave room for states to interpret specifics. In Arkansas, for example, proof of work was required monthly. Some states might require updates quarterly or be more flexible with exemptions. We’ll have to wait for the final regulations.
Epicenter NYC: How would these changes ripple into other safety net programs like SNAP?
Sarah Miller: There’s evidence that getting sanctioned in one program makes it harder to stay enrolled in others. A recent study on TANF’s work requirements found that sanctioned participants were also less likely to stay on Medicaid and their kids, too. These programs are interlinked — so hurdles in one can create disruptions in others.
Epicenter NYC: Just to clarify, eligibility isn’t shared between these safety net programs, but the processes overlap?
Sarah Miller: Correct. Losing Medicaid due to work requirements shouldn’t affect SNAP eligibility directly, but the shared administrative burdens can cause problems.
Epicenter NYC: Some officials justify these proposed changes by citing fraud. What do we know about fraud and abuse in Medicaid?
Sarah Miller: Like Medicare and private insurance, there’s probably some fraud, but Medicaid includes built-in safeguards. Every state has a Medicaid fraud control unit. The federal government also audits Medicaid payments. The last audit found that 95% of payments were proper.
The remaining 5% were labeled “improper,” but that mostly reflects paperwork errors, not fraud. For example, missing diagnosis codes. About 80% of those cases are administrative issues. Medicare actually has a higher improper payment rate. So while fraud exists, it’s not disproportionately high in Medicaid.
Epicenter NYC: How are undocumented immigrants currently served by Medicaid, and how might these changes affect them?
Sarah Miller: Undocumented immigrants are not eligible for Medicaid under the federal-state partnership. Most lawfully present immigrants also face restrictions. However, some states — New York included — use state funds to cover certain undocumented groups, like children. 14 states do this.
Epicenter NYC: We’re hearing that major hospitals in New York City are already feeling financial strain under the current administration. Anecdotally, some immigrants — many of whom rely on Medicaid, one of the largest health care payers — are making fewer hospital visits due to an increasingly anti-immigrant climate. What impact could Medicaid cuts have on hospitals and emergency rooms in NYC?
Sarah Miller: Hospitals would likely see an increase in uncompensated care. EMTALA requires them to treat patients in emergencies regardless of ability to pay. If more people lose Medicaid, hospitals absorb those costs. Many already operate with slim margins. While I can’t speak to NYC specifically, in Michigan there are serious concerns about hospital closures. Even uninsured patients will still need emergency care, and that puts pressure on the system.
Epicenter NYC: What are the biggest misconceptions about Medicaid and these proposed cuts?
Sarah Miller: A big one is the idea that Medicaid is some kind of unearned luxury. That narrative sounds like outdated conversations around cash welfare. But Medicaid provides essential medical care — not cash for discretionary spending. We know from research that losing coverage increases mortality. This isn’t a handout; it’s a basic need.
Epicenter NYC: Based on your research, how does Medicaid affect mortality and overall health, especially for vulnerable populations?
Sarah Miller: One study focused on low-income adults aged 55 to 64 — just before Medicare eligibility — who are at higher risk of health issues. My co-authors and I used a large dataset to compare mortality rates in states that expanded Medicaid versus those that didn’t after the Affordable Care Act. Because the 2012 Supreme Court decision made expansion optional, some states opted out despite federal incentives. That created a natural control group.
We found significantly lower mortality in expansion states. Over four years, an estimated 15,6000 additional deaths occurred in non-expansion states.
There’s also been a replication of our study using a larger dataset, which found mortality dropped about 20% across various groups — young people, racial and ethnic minorities, and more. That aligns with what you’d expect: when people gain coverage and access to care, health outcomes improve.
Epicenter NYC: What else should we know about the possible Medicaid cuts?
Sarah Miller: Besides the health benefits, Medicaid offers financial protection. Medical emergencies can lead to devastating bills — $5,000 or $10,000 — that some households simply can’t absorb. We’ve seen that when people gain Medicaid, bankruptcy rates drop and overall financial health improves. That also protects hospitals from unpaid bills. So Medicaid isn’t just about health; it’s also about economic security.
Epicenter NYC: What should New Yorkers relying on Medicaid or SNAP do to prepare?
Sarah Miller: At this stage, the best action is contacting your representatives to voice opposition to burdensome work requirements. Once the rules are finalized, people will need to be hyper-aware: check mail regularly, respond to any verification requests immediately. Unfortunately, staying covered may require more vigilance and paperwork.
This post has been updated to reflect breaking news.
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