This is an article written by one of our students, Jackson F. The opinions expressed herein do not reflect those of Civitas other than respect for the value of open dialogue. To read more Civitas Examiner stories or to submit your own, click here.
The One Big Beautiful Bill Act refers to the mega-bill recently passed by a Republican majority in Congress that covers a variety of issues from wages to welfare to technology, and perhaps what many experts consider the most impactful area of change, healthcare.
According to the Congressional Budget Office, the bill will likely result in historic funding reductions to Medicaid, Medicare, and other healthcare programs. A UC Berkeley Public Health report warning that nearly 12 million Americans could lose their health insurance.
This was met with staunch opposition from nearly all of the Democratic Congressional Caucus, along with a few Republicans. After several near-failures, the bill ultimately passed through both chambers of Congress and was signed into law by President Trump. Experts have warned of the negative consequences this bill could have across the board, particularly on the issue of healthcare, which has been an uphill battle for Missouri for nearly two decades. Many rural hospitals across the state are currently at significant risk of closure, with 12 rural hospitals closed between 2014 and 2023, and
another 25 are at risk of closure due to financial challenges, according to a report from KCUR (the NPR affiliate in Kansas City). On top of that, 7.5% of the state is uninsured, which is slightly below the national average of 8%, though rural areas tend to have a higher rate, closer to 9.5%.
Missouri also suffers from a large number of premature deaths from preventable causes, ranking 43rd in the nation according to the Commonwealth Fund’s 2025 Scorecard on State Health System
Performance. This is in conjunction with one of the highest rates of medical debt and avoidable costs in the whole country, as nearly half of Missouri adults report having experienced some medical debt, which is about 9 percentage points higher than the national average, as stated by a debt survey run by the Missouri Foundation of Health.
Background on the BBB
The One Big Beautiful Bill Act, as it’s officially called, is a federal statute and mega-bill initially introduced in the House by Jodey Arrington (R-TX) as H.R. 1. The bill, almost 1,000 pages long, contains hundreds of different provisions that span multiple issues across government, such as tech deregulation, tax code changes that benefit high-income earners, and reductions in healthcare spending. The initial bill passed the House on May 22 in a 215-214 vote. After a few amendments and some adjustments, the Senate passed the bill 51-50, with Vice President JD Vance casting the tiebreaking vote. The amended version was then sent back to the House, where it passed 218-214. President Trump signed the bill into law on July 4, 2025. Both of Missouri’s Senators (Eric Schmitt and Josh Hawley) voted for the bill, though Senator Hawley said he was opposed to the Medicaid cuts in the bill and aimed to repeal those specific
provisions subsequent to the bill’s passage.
One of the main provisions of the bill is large cuts to both Medicaid and the Child Health Insurance Program (CHIP), with annual spending on each being reduced by more than $100 billion. Another provision is work requirements, with all able-bodied adults being required to complete at least 80 hours per month of work, community service, or study to be eligible for Medicaid. These changes are schedule to go into effect in late 2026. Other provisions include increased frequency of eligibility determinations,
restrictions on specialized care coverage, expansions of AI use to find Medicare and Medicaid payment errors, which could result in improper denials of coverage, and restrictions on immigrant enrollment in healthcare programs. The overall goal of the bill, in accordance with the proposed provisions, is to shrink federal involvement in healthcare by cutting spending and allowing for increased deregulation of the healthcare sector, and, according to proponents, promoting a philosophy of personal responsibility and market-based alternatives to the current system.
President Trump and other Republicans in government have touted the bill as a major victory. “This is the start of a new golden age for America. The One Big Beautiful Bill delivers what voters demanded—results for families, workers, and small businesses,” President Trump said. In a statement, the Senate Republican Caucus said “This bill restores greatness to the American economy and ensures our nation puts working families first. We stood firm, and because of that, America wins.”
Other Republican leaders in Congress like Speaker of the House Mike Johnson (R-LA) and Vice President Vance have praised the bill as a positive for America.
However, healthcare experts have raised concerns over what the bill’s impact could be. Peter Reilly, the American Healthcare Practice Leader at HUB International, said “The impact is going to be profound, and the ripples are going to go not just across the healthcare industry, but for anyone who may work with and within the industry.” Director of the Medicaid and Uninsured Program at KFF Robin Rudowitz said “When combined with other policy shifts, Trump’s bill might result in around 17 million people losing their health insurance.” Researchers at the University of Pennsylvania’s Leonard Davis Institute of Health Economics said, “Researchers projected that the bill’s Medicaid cuts, shortened Affordable Care Act enrollment windows, and new administrative hurdles could increase the nation’s uninsured population by 60% and result in more than 51,000 additional deaths each year.” Other politicians and notable figures voiced their opposition as well. Former head of the Department of Government Efficiency (DOGE) Elon Musk called the bill a “disgusting abomination” and called on Republicans in Congress to “kill the bill”. Senator Chuck Schumer called the bill “nasty” and harshly condemned many of the cuts that the bill proposed. According to a July 2025 Washington Post-Ipsos poll, only 23% of Americans approve of the bill, while nearly 42% oppose it.
Detailed Dive into Missouri’s Healthcare System
Missouri has been facing a wave of rural hospital closures in the last decade, many of those hospitals serving populations of 10,000 or more. For example, Noble Health, a hospital in Mexico, Missouri, shut down in 2022 without notice, leaving tens of thousands of people in the area without access to nearby healthcare services. The state also has significant problems with its healthcare funding. According to a Missouri Medicaid Basics report, Missouri receives around $10.5 billion in Medicaid funding annually, and hospitals in the state do receive financial support from these funds. But healthcare experts have raised concerns that this funding often doesn’t translate into measurable improvements in patient care, staff safety, or health outcomes. According to state officials, 12 rural hospitals have closed in Missouri since 2014. “Rural healthcare continues to face significant challenges marked by provider shortages, geographic barriers, hospital closures, and high rates of chronic illness” said Maya Casaregola, the Director of Community Health at Phelps Health in Rolla, Missouri. “In Phelps County specifically, while we are fortunate to have a regional hospital, we still see disparities in specialist availability, behavioral health services, and timely access to care.” Missouri has also seen troubling statistics with Medicaid losses. According to a Washington University report, nearly 200,000 Missourians lost Medicaid coverage between June 2023 and May 2024, with Missouri having one of the highest Medicaid termination rates in the country. In 2023, about 10% of registered nurse positions in the state were vacant, with about 16.1% of registered nurses leaving their positions in 2024, as stated by a report by the Missouri Organization of Nurse Leaders. As a whole, the state has also struggled with health inequity, with the 2024 State Health Assessment reporting that the life expectancy in the state was significantly lower among African Americans and residents of the state’s most impoverished areas, with some counties in the Bootheel only reporting life expectancies around the 65-year mark, while more affluent and majority-white counties and localities like St. Charles tended to have higher life expectancies on average (usually in excess of 80). According to the same report, women’s health in the state also lagged, with Missouri ranking 31st in infant mortality and 40th for women’s health as a whole, both among the lower third of states. The healthcare system in Missouri has also struggled with more systemic issues like high suicide rates and frequent mental health issues, especially in lower-income areas, which, as a whole, tended to contribute negatively to state health outcomes. Missouri also currently faces a significant shortage of primary care physicians and psychiatrists, especially in many rural areas. These combined challenges have turned Missouri’s healthcare system into one of the most strained in the entire country, according to many healthcare experts.
What will the bill do?
Based on what we know about the current system, the Big Beautiful Bill will have significant effects on Missouri’s healthcare system. Missouri currently struggles under the weight of its current healthcare problems despite receiving nearly $18 billion in Medicaid funding every year. A $1 Trillion cut for Medicaid and CHIP funding nationwide over the course of 10 years would come out to roughly $100 billion in cuts per year, which, assuming the cut is spread proportionally, could represent a reduction of $2 billion per state each year in Medicaid and CHIP funding, equivalent to around 12% of Missouri’s entire Medicaid/CHIP budget, though it’s important to note that the impact could vary by state. Further cuts to it could potentially see thousands of people, especially in rural areas, lose their Medicaid coverage, which could potentially worsen affordability challenges. CHIP funding cuts will also hit women’s and children’s healthcare hard, with CHIP specifically being the entity that funds healthcare coverage for children and pregnant women in low-income families. Cuts to this program will cause similar affordability issues for thousands of people across the state. Medicaid and CHIP cuts will also significantly affect the operability of both systems in Missouri. Medicaid funding not only covers care for low-income people but also supports the administration of the program, which already struggles with issues such as registration delays, eligibility screenings, and prescription access. These cuts will simply make the system more difficult to operate in an already strained system with a myriad of shortages, and could result in further disenrollment from the program, and making it harder for everyone else to maintain their coverage or sign up for coverage. On top of this, the new work requirements that the bill proposes will also impact low-income individuals and families hard, as many below the poverty line already struggle to hold down jobs or are unemployed due to the lackluster job market in a lot of rural Missouri. The work requirements, like a lot of the other cuts in the bill, will primarily impact people below the poverty line and in poorer rural areas that are already struggling with healthcare. The increased frequency of eligibility determinations are also a part of the bill that could end up cutting even more people off of Medicaid coverage due to the already existing lack of screenings and consistent problems with registration. There are other minor parts of the bill that could have a lesser effect than some of the main provisions but would still pose a potential risk to Missouri’s healthcare system as well. One of these minor parts (speaking from the vantage point of Missouri) is the big changes to the eligibility of immigrants, particularly undocumented ones, to receive healthcare benefits through rolling back the FMAP provided to “unlawfully present aliens”, while also limiting premium tax credit eligibility for that same group of people. While the population of undocumented immigrants in Missouri isn’t particularly abundant, this could impact the small existing Latino and undocumented immigrant community in the state. The bill also fully prohibits federal funding for specified family planning and abortion service providers (in conjunction with cuts for Planned Parenthood) and has the potential to negatively impact women’s health access.
However, there are a few aspects of the bill that could potentially offset many of the more catastrophic effects that the bill could have on Missourian healthcare. In the bill, there is a $50 billion-dollar rural health transformation program that is aimed at preventing rural hospital closures, though it’s important to note that this won’t directly provide relief to rural hospitals like other past relief attempts have, but rather gives grants to states, with Centers for Medicaid Services having significant discretion over how each state uses those funds. This rural health fund is the only part of the bill that aims to increase funding for healthcare services or programs, though.
As a whole, all of these proposals, in one way or another, will generally have a negative impact on Missouri’s healthcare system as a whole, with some positive caveats in between the lines.
