One Big Beautiful Bill Act: The impact on physicians and patients

Featured topic and speakers

Significant changes to health care are on the horizon now that the One Big Beautiful Bill Act of 2025 (OBBBA) has been signed into law: Medicaid eligibility and financing, access to health insurance coverage through Affordable Care Act marketplaces, federal support of medical student loans, and Medicare payment. What do physicians need to know and how they can help their patients navigate these changes? How is the AMA helping state medical associations prepare for implementation?

Watch this Advocacy Insights webinar on OBBBA implementation. 

Host

• David H. Aizuss, MD, chair, AMA Board of Trustees 

Speakers

• Todd Askew, senior vice president, AMA Advocacy
• Emily Carroll, senior attorney, Advocacy Resource Center, AMA
• Annalia Michelman, senior attorney, Advocacy Resource Center, AMA

Transcript

Dr. Aizuss: Well, hello and thank you for joining us this evening for our latest in the AMA Advocacy Insights webinar series. I'm David Aizuss, board chair of the American Medical Association and an ophthalmologist from California. I'm pleased to be with you today for this important discussion. 

The One Big Beautiful Bill law made changes to federal programs that are important for physicians and critical to the health and well-being for some of the most vulnerable patients in our communities. Throughout the process of this bill being signed into law, the AMA made our priorities clear and outlined the impacts that could occur when it passed. We advocated against provisions that will severely cut funding for federal health programs and restrict access to health coverage. 

According to the Congressional Budget Office, the CBO, the OBBA will increase the number of people without health insurance by 10 million in 2034. Additionally, if the ACA's enhanced premium tax credits are not extended past the end of 2025, CBO estimates that the number of uninsured people will increase by more than 14 million in 2034. 

We also made clear that the law makes changes that needlessly create more barriers to people pursuing careers in medicine. These changes make the high cost of medical school even more unaffordable and will surely exacerbate an already alarming physician shortage.

We also strongly protested against a proposed 10-year moratorium against any state or federal regulation of artificial intelligence provisions that were ultimately removed from the bill as a result of our advocacy. And the OBBA failed to alleviate much of the financial pressure physicians experienced caused by two decades of declining payments through Medicare. The law did include a temporary one-year 2.5% update for 2026. But this was a far cry from the physician payment updates included in the House-passed version of OBBA that would have altered the statute and linked reimbursement to a rate of inflation equivalent to the MEI, the Medicare Economic Index. 

The House version of the OBBA provided physicians with 75% of MEI permanently added to the baseline in 2026, followed by permanent updates of 10% of MEI in 2027 and beyond. The House-passed version, however, was ultimately scrapped in favor of the Senate bill, which in turn leaves no permanent inflation-adjusted payment update in place. 

Clearly, this law is going to have a major impact. And today, we wanted to outline what physicians need to know and how these changes are going to affect their patients. We also wanted to highlight some important opportunities for states to mitigate coverage losses. 

So today, while we mention many provisions, we're really going to focus on Medicaid eligibility and financing as well as access to health insurance coverage through the Affordable Care Act marketplaces. Joining us today are three experts on the subject—first, Todd Askew, our senior vice president for AMA Advocacy; next, Emily Carroll, a senior attorney in our Advocacy Resource Center at the AMA; and finally, Annalia Michelman, a senior attorney also in our Advocacy Resource Center at the AMA. 

First, we're going to hear from Emily and Annalia, who will present some details on various provisions of this law. Then Todd will be able to answer some key questions that will help give greater clarity on how this law will impact physicians and our patients. I also want to make sure we have enough time to discuss these important issues and answer your questions. So let's get started. 

Michelman: Hi, everyone. I'm Annalia Michelman. And as Dr. Aizuss just noted, the One Big Beautiful Bill brought some of the most consequential changes to federal health policy that we've seen in more than a decade. It reshapes Medicaid, CHIP, the marketplaces, and even touches on Medicare and medical education. As we just noted, today we're going to focus in on just two of those areas, Medicaid eligibility and financing and marketplace coverage and affordability. You can go to the next slide, please. 

So on the Medicaid side, the law imposes new work requirements. It shortens renewal periods. And it adds other administrative barriers while also restricting how states finance their share of costs and how they pay providers. And then on the marketplace side, it shortens enrollment windows, eliminates automatic re-enrollment, and makes it harder to get and maintain affordable coverage. And so together, these changes are expected to leave up to 15 million people without insurance. 

Most of those coverage losses will come from Medicaid, as patients are tripped up by these complex new reporting rules and administrative barriers. Millions more will lose their marketplace coverage. And when patients lose coverage, we know the consequences. For patients, it means delayed/foregone care, worse health outcomes and financial hardship for families. For physicians, it means more uninsured and underinsured patients, less stability and safety net financing, and growing pressure on already strained practices. That's especially true in rural and underserved areas. 

The financing changes are going to exacerbate these challenges. States are going to be severely restricted in how they generate revenue to support their programs. And it's going to force some pretty difficult decisions about benefits, eligibility and reimbursement policies. 

Now, as Dr. Aizuss said, the AMA opposed these provisions throughout the legislative process. But now the law is in effect. And so our focus is now shifting to implementation. States will determine how much of this harm can be mitigated. And hopefully, in some cases where there's some opportunities—can emerge. 

So with our focus on implementation, we're working very closely with the state and specialty medical societies to help shape those state decisions. We're identifying where flexibilities exist and how we can equip advocates with the tools they need to influence those processes. So that's the lens through which we'll look at all of these key provisions today—how they work, what they mean for physicians and patients, and where the AMA and our federation partners can make a difference. Next slide, please. 

So moving into some of the specific Medicaid provisions—you can go on to the next slide. So as mentioned before, these Medicaid provisions in the bill make it harder to get and keep Medicaid coverage. And this is through, really, a number of provisions. It's too many, I think, for us to cover in this webinar tonight. So I'm going to focus on just six of the ones that I think are more impactful. But I do want to emphasize that these are not—what I'm going to cover tonight is not the entirety of the changes facing the program. Next slide, please. 

So the first topic that I want to cover is the community engagement rules for Medicaid, otherwise known as work requirements. For the first time, states are going to be required to implement work reporting requirements for the Medicaid expansion population, which is adults between ages 19 and 65. And they're going to have to implement this by January of 2027, which is a really short timeline for implementation. 

These provisions, the work requirements, are expected to reduce federal spending by $326 billion over 10 years. This is the largest share of federal Medicaid savings in the bill. And those savings come from coverage losses—that people won't be able to keep up with these requirements, and they'll lose Medicaid. This is estimated to lead to coverage losses exceeding 5 million people by 2034. 

And importantly, these work requirements only apply to the Medicaid expansion populations. And here's the requirement. They have to engage—or they have to report, I should say—they have to report at least 80 hours of work, community service, or participation in a work program per month, or they have to be enrolled in an educational program for at least 40 hours per month or have a monthly income of at least $580 per month, which is the monthly equivalent of working for minimum wage for 80 hours. Next slide, please. 

So at application, when somebody applies, states are going to need to verify at least one month of compliance with these new rules. But they can choose to require up to three months. And then anybody on Medicaid periodically has to submit documentation to show that they are still eligible for the program. 

At that renewal point, they will have to demonstrate they've complied with the work requirements for the—during the previous six-month period. And anybody who can't show compliance will be terminated. And if they need to reapply, they'll have to show—they'll have to document their work activity all over again. 

Now, states are instructed to use in the law existing data sources where possible, such as claims data or other data that might verify somebody's income. This is supposed to be so that Medicaid beneficiaries don't have to provide additional documentation themselves. But importantly, really importantly, anybody who loses coverage due to non-compliance with these work requirements—not only will they be terminated from Medicaid, but they'll also be barred from subsidized marketplace coverage. So without marketplace coverage, without Medicaid—and most low-income people don't have access to employer-based coverage—they'll effectively be locked out of health insurance coverage. 

And the experience that we've had in a few states who've had work requirements for Medicaid in the past—we know that these coverage losses, these disenrollments, are not going to come from people who refuse to work. They will come from people who are eligible, but they get tripped up by the paperwork or there's reporting errors. Next slide, please. 

The law does provide some exemptions for certain individuals. And this is going to be a really key piece of implementation for states. This is not a comprehensive list here on your slide of the exceptions, but it's many of the important ones. 

There is an exception for individuals who are medically frail. And "medically frail" is a term of art in Medicaid. It's not necessarily a appropriate description of any given beneficiary. But it includes four different categories—individuals who have substance use disorder, a disabling mental disorder, a physical, intellectual or developmental disability, or a serious or complex medical condition. 

There's also other exceptions that are important, like people who are participating in a drug or alcohol treatment program, people who are meeting the work requirements for TANF or SNAP. There's also a exception for caregivers of dependent children under 14 or of other disabled individuals. 

States are also allowed to offer an optional hardship exception, as well, for three different categories. They can offer an exception, but are not required to, for individuals receiving certain services, like inpatient care, for people living in areas with an emergency or disaster declaration, or for people who need to travel outside of their community for extended periods of time in order to receive care or to take a dependent child outside of their community for extended periods in order to receive care for a serious or complex condition. 

So the AMA is working with stakeholders and states to ensure that these exceptions are as flexible and patient-centered as possible, really emphasizing streamlined verification here and acceptance of reasonable documentation when it's appropriate. We're also really urging states to collect and share data early so that we can track who's losing coverage and understand why. 

So physicians and state and specialty medical associations can also and should also help shape these rules. Engaging with your Medicaid agencies to advocate for flexible exceptions is a really important step. Educating patients about these new requirements is another. Clinics and health systems and physicians can communicate directly with patients so that they understand what documentation needs to be provided and where they can go for help. And our goal here is really to ensure that no one loses coverage simply because the process is too complex for them to navigate. 

Six-month eligibility redeterminations—so the bill also cuts the Medicaid renewal period in half. This is when Medicaid patients have to show that they're still eligible for the program. So it's cut in half from 12 months down to six months. And this applies, again, just for the Medicaid expansion population. This provision is expected to save the federal government $63 billion. And again, the savings here is because people are expected to lose coverage. 

There's CMS guidance due by January. And states have to implement these more frequent redeterminations beginning in January of 2027. CBO estimates that another 700,000 people could lose coverage as a result of these more frequent renewals. And we saw what happens with this during the Medicaid unwinding after the COVID public health emergency ended. Procedural barriers drive most disenrollments here, not changes in eligibility. 

We are encouraging states to make these redeterminations as automatic as possible. We're also really encouraging feedback loops with medical associations, plans, practices, state government to track the outcomes here and flag problems early. That was very important during the Medicaid unwinding after the public health emergency ended. Physicians and practices can also play another direct role here, again, just like with the work requirements, in helping patients understand how to maintain their coverage, that they need to update their contact information, for example, and that they need to respond promptly to their renewal notices. 

So moving on to provider taxes, these are—this is one of the financing provisions. So all but one state currently relies on provider taxes to finance their share of Medicaid. And the One Big Beautiful Bill really sharply limits states' flexibility in generating revenue for Medicaid programs in this way. Beginning in October of 2026, all states are effectively barred. 

Wait, why did I say—sorry, I have the date wrong. But all states are effectively barred from establishing any new provider taxes or increasing rates on existing ones. For non-expansion states, the law, effectively, grandfathers existing tax rates in. So non-expansion states can keep what they have. But they can't change their tax rates or add any new ones. 

For expansion states, the grandfathering is much more limited. What's known as the hold harmless threshold in provider taxes, which is currently set at 6% of net patient revenue, is going to be lowered beginning in 2028 by half a percent per year until the threshold is three and a half percent in 2032. 

Now, states that depend on these provider taxes are looking at really significant budget shortfalls. And like I said earlier, they're going to be forced into some really difficult decisions. These reductions in provider tax rates are going to mean less state funding available to sustain reimbursement and less funding available to cover some of those optional Medicaid services and those optional Medicaid groups. 

Some of the points of influence here—so state medical societies should, and they are, assessing what the exposure is now—which provider groups are taxed, how much revenue supports Medicaid reimbursement rates, what the phase-down will mean. And we're working with the states, as well as state medical societies, to develop some mitigation strategies, as well, identifying what some of the alternative federal funding sources might be, as well as was identifying any policy adjustments that might be available to stabilize physician participation in Medicaid, even when those reimbursement rates might come under pressure. Our goal here is to make sure that the program is adequately funded and that physicians remain able to see Medicaid patients, even as these financing options narrow. 

So the law also caps future state-directed payments. These are payments made through Medicaid managed care organizations at the direction of the state. So state-directed payments are capped for expansion states at 100% of Medicare rates. And in non-expansion states, the cap is set at 110% of Medicare rates. 

Currently, the cap is set at the average commercial rate. So we're looking at a pay cut here. Existing state-directed payments above that level will be phased down by 10 percentage points each year until they reach the cap. 

Now, there's an important point to this, which is that the cap applies to four categories of services—inpatient and outpatient hospital services, nursing facility services and professional services at academic medical centers. It does not limit state-directed payments for other professional services. 

However, CMS has said that they are considering changes that would affect additional services beyond these four. So regardless, because so many states rely on these state-directed payments to stabilize hospital and physician payment rates, these caps could mean some pretty real dollar cuts to reimbursement. 

So as with provider taxes, the impact here is really going to depend on what the state currently has. And so state medical societies are working with their Medicaid agencies now to understand what the exposure is and to identify some solutions to make up for some of that funding, if necessary. Our priority is to prevent compounding of these payment cuts in order to protect access to care for low-income patients. 

So two additional provisions that I want to touch on—the first is Medicaid coverage for non-citizens. The One Big Beautiful Bill eliminates full Medicaid and CHIP coverage for most non-citizens. That includes for refugees and asylum seekers. And it really leaves only a narrow set of eligible groups of non-citizens that will be able to get full Medicaid coverage. 

Now, non-citizens who are not eligible for full Medicaid can use what's called Emergency Medicaid to access emergency services. In states that had expanded Medicaid, the reimbursement rate for Emergency Medicaid had been set at 90%. The federal match, the FMAP, is now going to drop down to the states' regular match here. So this is going to reduce the federal support even more for Medicaid programs, shift even more of those costs to states and to hospitals, and further strain the safety net. 

The last of the provisions that I want to touch on is retroactive Medicaid coverage. States will be required in—starting in 2027 to shorten the retroactive period from three months for the expansion population and two months for all other eligibility groups. Retroactive Medicaid coverage has long protected patients from medical debt. And it's also protected physicians, hospitals and others from the uncompensated care costs from uninsured people by covering care received before a Medicaid application is approved. 

So if somebody shows up to the hospital that is uninsured, but they're eligible for Medicaid, they can submit an application to Medicaid. Once it's approved, as long as the care provided was within the retroactive period, they can get those medical bills paid for retroactively. So reducing this means more unpaid bills for patients and more uncompensated care as well as more of a strain on the safety net. 

So those are some of the really impactful Medicaid provisions. As I said, it's not the entirety of all the Medicaid changes, but certainly the ones I think that are going to have the biggest impact. I want to turn it over, though, to Emily Carroll, my colleague. She's going to talk about some of the marketplace changes that are happening in parallel with these Medicaid changes. 

Carroll: So, yes, as Annalia mentioned, I'm going to talk about a few key marketplace ACA provisions that are really—as opposed to a single piece of legislation, changes to patient access and their ability to afford ACA marketplace plans are coming through a series of policy changes, including the One Big Beautiful Bill Act. There was also a final marketplace integrity rule that came out of CMS in June that had some significant changes to the marketplace and then, of course, as Dr. Aizuss mentioned, the expiring enhanced premium tax credits, which have been a central point of contention in the government shutdown. 

These are all really coming together like a perfect storm with all these policies. And as a result, experts are anticipating that millions of enrollees will lose their ACA coverage either because they can no longer afford it, they're no longer eligible for coverage or subsidies, or administrative changes to the enrollment program, as Annalia talked about in Medicaid, are preventing them from actually signing up. 

So I'm going to spend just a few minutes going through some of these changes and the impact on access, though it—certainly, it won't be comprehensive. But I did want to first mention that a number of the marketplace rule provisions are currently being challenged in court. 

So in July, a group of cities and organizations filed a lawsuit against the administration seeking a stay of certain provisions in that final rule. In August, the district court in the—for the District of Maryland issued a nationwide stay on several of the provisions, finding that they're either likely inconsistent with the ACA or arbitrary and capricious. And the administration is currently appealing that decision. So in the next couple slides, you'll see a little asterisk next to the provisions that are currently stayed or paused. 

So first, I want to look at affordability for marketplace plans. A provision in the One Big Beautiful Bill Act will mean that some low-income enrollees may end up with major financial obligations at the end of the year if their anticipated income at the beginning of the year is a lot—is less than their actual income. 

So for most tax credits, they're given as advance premium tax credits for ACA plans, meaning you have to predict your income at the beginning of the year. And the assistance is based off of that estimate. If that estimate is off and your income is higher, at the end of the year, there are repayment requirements. 

But currently, repayment limits vary by income. And very low-income people are protected by caps on those repayment requirements. But going forward, as a result of the new law, the caps that protect low-income enrollees from suddenly having to repay large tax credits are going to be gone. And they will potentially have major tax liabilities at the end of the year when they go to enroll. 

The final marketplace rule made several changes that are also going to impact affordability in marketplace plans. But as I mentioned, some of these provisions are currently paused. But for example, the rule would require an individual who has a $0 premium plan—so a very low-income individual—to pay $5 a month in premiums when they're automatically enrolled until they reconfirm their eligibility. It also ends the popular bronze-to-silver crosswalk that allows CMS to take them normally from a higher cost sharing bronze plan to—and move them into an identical and lower cost sharing silver plan, which resulted, generally, in better coverage for lower cost for that person. 

It also makes some technical changes that are—that I'm still having trouble wrapping my brain around. But basically, they're allowing plans more flexibility in their actuarial values. So that actuarial value is that level of generosity of coverage in each of those various metal levels in the marketplace—so your bronze, your silver, your gold. And they're also making some formulary changes that are decreasing tax credits and increasing cost sharing. 

But I would say probably in terms of affordability, the real culprit of affordability is the expiration of the enhanced premium tax credits. So as many of you probably know, these subsidies were enacted as part of the American Rescue Act in 2021. And they have significantly improved the affordability of marketplace plans. 

So really broadly, they increased tax credits for people with incomes below 400% of the federal poverty level. They also allowed those above 400% to qualify for some tax credits. And they capped cap premiums at eight and a half percent of enrollees' income. 

So as a result of those changes in 2021 until now, marketplace enrollment has nearly doubled to 24 million people. This increase has improved the overall risk pool. So that means that premiums are lower for all enrollees. And I think what we're seeing is the prospect of the expiration of the enhanced premium tax credits are ... affordability. 

We know that plan premiums for next year have gone up about 30% as plans begin to anticipate healthier patients leaving the marketplace. And that's certainly, at least partially, because of the end of the enhanced subsidies. And then when you factor in the actual expiration of the tax credits, a lot of patients are going to more than double their out-of-pocket costs for premiums next year. So for many folks, that's just not an increase they can manage. 

So talking about enrollment changes, as well, the final marketplace rule, combined with the new law, is also going to result in a lot of enrollment challenges for folks, impacting the number of people who can sign up or who are going to sign up for coverage. So first, under the final rule, we're going to see enrollment period shortened by a month. 

So states that use the federally facilitated marketplace or states that use the federal marketplace for their enrollment period—or for their exchanges are going to see their enrollment periods decrease from November 1 to December 15. And that used to go until January 15. For state-based exchanges, we'll—they'll have a little bit more flexibility. But they'll need to keep their enrollment periods to no more than nine weeks, too—so a significant cut as well. 

And then in the new law, combined with the federal, they essentially end the Special Enrollment Period, or the SEP, for low-income individuals who are not eligible for Medicaid. So previously, people with incomes at or below 150% of the federal poverty level qualified for an SEP to enroll in a marketplace plan or switch plans at any time throughout the year. And this was established in 2021 and turned out to be a really important pathway for folks to get into the exchanges. 

In one year, over a million people signed up using these SEPs. But the new law bars people from receiving tax credits starting on January 1 if they enroll through one of these SEPs that is based on income. So that, essentially, because these are low-income individuals, restricts them from entering the marketplace. 

And perhaps, I would think, the most important change to enrollment is the end of the automatic re-enrollment. And now folks will be required to go to the marketplace, re-enroll, and verify their information, even if nothing has changed. This is a really massive change, in our opinion. 

I don't know about you, but I receive many emails every year on open enrollment. And I still occasionally miss that period. But I'm always automatically re-enrolled in the same or similar coverage. And the same applies for marketplace enrollees. 

This year, 10.8 million of the 24 million enrollees chose to automatically re-enroll in their plan. So that's about 45% of enrollees. So there's going to need to be significant outreach and education to help enrollees stay covered with this change, not to mention all the new state processes it will require. 

And finally, there have been some significant changes to who is eligible for marketplace coverage and subsidies. The immigrant community was probably hardest hit by these changes. Under the new law, new categories of lawfully present immigrants, such as refugees, asylees and those with temporary protected status, are no longer eligible for subsidies. So many low-income immigrants will not be able to get coverage on the exchanges. 

Additionally, starting next year, immigrants who are below 100% of the federal poverty level and waiting the required five years to become eligible for Medicaid won't be able to purchase care in the marketplace in the interim. And then finally, the rule ended marketplace access for all DACA recipients. So over 10,000 people have already lost coverage because of that provision. 

And there are a number of other provisions/final rule that will impact eligibility. But most of those are still currently stayed. And then another major change under the new law is the end of provisional eligibility. So this will prevent individuals from accessing subsidies for a limited time while their eligibility is being verified—so really potentially straining folks in the interim, while they're getting all their paperwork and information submitted. 

So what does this all mean? The marketplace, where 24 million people currently have coverage and where one in seven of us will seek coverage at some point, are going to be challenged in the coming years to offer affordable health insurance. 

These changes all together are going to result in fewer folks accessing marketplace plans with all of these new administrative requirements, the shortened enrollment period, and the end of auto enrollment. And for those that stay in the marketplace, there's going to be higher premiums and costs as the risk pools get less healthy. And then in the coming years, we'll also need to worry about patient choice of plans and competition among marketplace health plans. 

And of course, this is all happening in real time. Open enrollment began on November 1. And enrollees are already encountering these premiums and cost-sharing increases. Some individuals are going to see increases of up to 114% in their net premiums and just simply walk away from purchasing health insurance. 

Those who walk away are actually probably going to be folks who are healthier and don't anticipate their health care needs exceeding the higher premiums. And as healthy people leave the exchange, it only exacerbates rising costs by skewing the risk pools.

I think we would argue that in the face of all these coverage losses, there is opportunity for the AMA, medical societies, physicians to influence the extent of the final impact. Certainly, intense advocacy around extension of the enhanced premium tax credits by the AMA, medical associations and other huge coalitions of stakeholders continued—or continues. I've been told by very smart people that while the best day to extend the tax credits is today, if and when it does happen, state-based marketplaces and the federal exchange will be able to quickly adjust and ensure improved affordability of plans. 

But in addition and looking forward, I think there's important ways for all of us to engage, including connecting with your state policymakers and coalitions in your state to emphasize the importance of affordable and comprehensive coverage. I think physicians have a really powerful perspective in that you know what coverage means in terms of health outcomes. And you know what the system can carry in terms of the uninsured. 

So we really encourage you to be a trusted resource in your state to policymakers. And you can help patients who are trying to understand insurance changes, connecting them to the enrollment assistance and helping them understand why it's so important to have comprehensive coverage. We know these are big asks with already strained resources. But the AMA is going to be working to help you along the way with tools and resources to take this on. 

And so we also want to point out that we know that the One Big Beautiful Bill Act is a massive law impacting numerous sectors and included several other provisions impacting health care and physicians. First, the bill made some major changes, as Dr. Aizuss said—well, I don't know major—but made some changes to Medicare physician payment and included a two and a half percent increase in 2026 payment rates. 

Additionally, the new law expands and clarifies the exclusion for orphan drugs under the Medicare Price—Drug Price Negotiation Program. And non-citizens are now generally restricted from accessing Medicare coverage. 

In terms of student loans, there have also been some changes to both the caps on the amount that medical students can borrow as well as changes to repayment options. You can see on the slide the law eliminates Grad PLUS loans and caps unsubsidized federal loans at $200,000 in total. There are also changes to the total amount of any student loans and the amount for Parent PLUS loans. 

The new law also attempts to simplify and streamline the loan repayment process, although it will benefit borrowers—is still a question we're analyzing. If you're done taking out loans and in a repayment plan, you're essentially grandfathered in and can keep going with that plan. 

But if you are in the process of taking out new loans or you're going to take out loans in the future, you'll have less choice in your repayment going forward. There will, essentially, be two types of repayment plans, the rep and the new standard plan. 

So I think there is—we think there is a potential for a brief gap where you could end up with two different repayment plans. But borrowers will ultimately be funneled into one of those new repayment plans. 

We're committed to helping students understand these changes. And we're creating resources on this that will be coming your way shortly on our AMA GME advocacy page. And I'm sure that's something we can send out to you all and follow up to the attendees of this call in the coming week. 

If you're a visual person, we just wanted to offer this timeline so you can picture when these Medicaid and ACA changes are kicking in and what the next couple of years are going to look in terms of policy changes. So with that, I think I will kick it back to Dr. Aizuss, and we'll start taking some questions. 

Dr. Aizuss: Well, those were two incredible presentations. Thank you, Annalia. And thank you, Emily. I think what we'll do now is we'll go to Todd. And I have a few questions for you. And then we'll see if there's any audience questions. So first, Todd, what is the AMA's approach now to OBBA implementation and finding opportunities for us to mitigate harm to both patients and physicians? 

Askew: Sure. Thanks, Dr. Aizuss. I think what you heard both Annalia and Emily, especially Annalia, say is much of this law has been left to the states to implement, that we are at the very beginning of that period, not at the end—that the bill was passed, but that's not the end of it. 

There's a long road, as shown in that last slide that Emily had, on implementing some of these provisions. And I hope you took from some of Annalia's comments that this is not a fait accompli, that there are opportunities here to impact the way people can preserve their coverage, the way that state medical associations can influence states to make it easier for people to maintain their coverage. 

So there's a lot of opportunity here to change the outcome. It's not predetermined that 10 million people are going to lose coverage. We have an opportunity to impact that. And maybe I could talk to—ask Emily to say a few words about some of those opportunities that state medical associations and individual physicians have to impact the way this plays out. 

Carroll: Yeah, it's such a good point, Todd. Like you said, so much of the work to mitigate the harm is now on the shoulders of state policymakers and advocates. And all these points of influence are opportunities for folks in the states to act. 

So for example—I'll just throw out a couple examples of where I think states and physicians and advocates can step in—states are going to need to capitalize on some of the flexibilities in the federal requirements where they can, including amending state laws to define work requirements and exemptions. They're going to need to establish exceptions to the rules where it's allowed. States in—with state-based exchanges are going to need to capitalize on some of the flexibilities they have because of that setup. 

States are also going to need to update state plans and 1115 waivers to reflect limitations on the provider payments and changes in coverage. And they're going to need to build—or rebuild eligibility systems with these biannual renewals, work tracking, immigration status, the end of auto renewals and the new ACA verification requirements. 

There's going to need to be adjustments in state budgets for some of these lower fundings. States are going to need to renegotiate their Medicare—Medicaid managed care contracts with these new provider caps or tax caps. And there's going to need to be a ton of community outreach and education campaigns on the work rules, the immigration eligibility changes, the enrollment periods, verification requirements and the bottom enrollment. 

So all these are actions where folks—advocates can step in and really make an impact. And then we also are beginning to think about other policies that we can, as advocates, begin layering on top of implementation to make sure we're protecting patients and physicians, like could your state establish policies to strengthen their marketplace? Are there protections against non-comprehensive coverage? Does your state have a reinsurance waiver? Are there good network adequacy requirements, because we know we're going to see more changes in that space? 

And we know what happens when plans get squeezed, too. They often start employing measures like utilization management, alternative funding programs, and other cost-shifting measures. So we need to think about establishing some of those patient protections. 

I'd say workforce issues are going to be a really big issue to layer on top of those—how we can invest there. Ensuring physicians and hospitals are participating in Medicaid—what incentives can we establish there? And then what policies can we put in place to protect the uninsured and account for the increase in uncompensated care that we're going to see? Those are opportunities where all of us can work in our states to make sure we're influencing the outcome and really mitigating some of the harm that this bill could cause in the states. 

Dr. Aizuss: So given the fact that, Todd, all this is impacting us at a state level and the implementation is primarily at a state level, is the AMA doing anything in particular to help state medical associations counter this? Are they providing resources through our Advocacy Resource Center? Are we developing model legislation to somehow modify some of this stuff as it's being implemented for the better? Can you give me some information on what's happening at the AMA with regard to that? 

Askew: Sure, absolutely. So one of the first things that's going to happen—well, this is all happening at the same time. But we're going to see a federal rule, too, that essentially provides some guidance to states on how they should go about implementing that.

So we are engaging, will be engaging, with the administration as that rule is developed. And then, obviously, in the formal notice and comment rulemaking period, which will occur in the spring to early summer of next year—to see what we can do to influence the guidance that the federal government is going to provide to the states to begin some of these steps. 

But you're absolutely right about the fact that the real work of this is going to be done by the states. And that's where our state medical associations have great relationships with their policymakers, with regulators, as well, in the United States. 

One of the things that AMA does very well is convene, is to share information, to coordinate activities and share opportunities between the different state medical associations. And we've already begun to do that through a series of calls in order to coordinate activities between different states to talk about—to convene small groups to talk about specialized issues that may be affecting only a small subset of states. 

We're working to develop a hub where states can share information and best practices with each other as they work with their regulators on some of these very difficult issues—also talking about opportunities for physicians to educate their patients, to say, this is what you need to do in order to maintain your coverage. This is the information you need to provide. These are the timelines you need to follow. 

That's all going to be very specific state by state as the plans come into place in each individual state. And I don't know. Maybe Annalia can share a little bit more information about what we're currently doing, but also some of the things we have planned to help states navigate this. 

Michelman: Yeah, absolutely. Thanks, Todd. So my unit and Emily's unit at the AMA, the Advocacy Resource Center—we are the state legislative and regulatory advocacy group. And we were really built for moments like this, helping states navigate really complex challenges like this. 

We are a team of seven attorneys. We're focused entirely on state advocacy. And our mission is to make sure that the state medical societies and the specialty societies have the tools and the resources that they need to shape state health policy. 

So for the One Big Beautiful Bill, the AMA has devoted really significant resources, staff, and financial resources to help states prepare here. And like Todd just talked about, one of our big functions is convening the federation. 

The network of state government affairs staff across the federation is really tight-knit. We talk constantly, sharing strategies, sharing model language, talking about early warnings about what might be coming. We think it's a really important function that we keep all of the federation connected. 

So like Todd said, we do that through—we hold weekly calls with the federation. We have some targeted small group discussions. We have listservs and webinars. We're developing a hub so that state advocates can upload and access others' advocacy resources, like letters and analyses. 

And so that way, nobody has to start from scratch. And we know that this network that we have is really powerful. We hear over and over and over again that bringing everybody together to share strategies and to learn from one another is a really valuable function. 

We also develop a lot of tools, issue brief summaries, that sort of thing. We're engaging with a lot of outside folks to help us with some of that. We're engaging with some former Medicaid officials, some tax experts. We're working with some—we're meeting with some current state officials to help guide some of this as well. 

We also partner with think tanks and other advocacy groups that develop research-based resources so that we can integrate data into our materials. We meet with those folks regularly to exchange information that helps shape their research. 

And it also gives us an opportunity to bring that data into our advocacy resources. And like Todd said, we're also planning to build out some communications materials for physician practices so that you all can help your patients understand the upcoming changes.

And then the last thing I'll say is that the Advocacy Resource Center also provides a lot of individualized state support. This is really at the heart of what the ARC does. We work one-on-one with the state medical associations, helping them craft a unique solution to whatever unique challenge they might have. 

Sometimes, that means reviewing or drafting legislative language. Sometimes, it means—in the past few months, it has meant advising on some of the provider tax structures and helping to figure out some of these Medicaid work requirement exceptions. 

A really good example of how all of these different functions tie together is the Rural Health Transformation Program. This is the $50 billion grant program created by the bill to provide to states over the next five years. 

States had to submit their applications by today. But in the lead-up to this over the past several months, we hosted several different webinars and calls with the federation staff to talk about different strategies to share proposals among the states. And we also produced some pretty detailed guidance on the application process and the scoring process. 

Several states also asked for our help analyzing specifics for their state. There was a lot of concern about one of the factors in the application that was around scope of practice. So we worked with individual states to estimate what was at stake financially with that and helped them think through ways to message the importance of protecting physician-led care in—despite the application factors. 

So the feedback that we get on things like that is really overwhelmingly positive. We hear that these kinds of collaborations really strengthen everybody's hand when they're sitting down with their state policymakers. We really want to emphasize that when it comes to state implementation of this bill, we are on it. 

We know that implementation is going to take years. And we know that there's challenges that we're not going to be able to completely prevent. But this is exactly why the AMA created the Advocacy Resource Center. We're here to help states navigate challenges like this. And we've devoted significant resources to doing it well. 

Dr. Aizuss: Thank you, Annalia. I have a lot of questions here from the audience. But given the fact that the AMA's Interim Meeting is starting next week, before we go to these questions, I wanted to give Todd an opportunity to tell us what are the key issues that the AMA is advocating on going into the interim meeting next week. What's a preview that you'll be telling people about? 

Askew: Sure. Well, obviously, what we've been talking about tonight and efforts we can all work to together as a federation to implement this bill in a way that is least harmful to patients and protects so many elements of the health care system is going to be a key issue. We also, obviously, have the perennial issue of physician Medicare payments. We have an update this year based—the two and a half percent update that came from this bill as well as some statutory updates. 

It's a mixed bag, though. The physician payment rule, as you know, just came out. And there's some provisions that shift a lot of dollars around within the health care system. Some physicians benefit. Other physicians are going to be negatively impacted. 

So we're going to have to work through a lot of those issues as we start looking at the implementation of those provisions starting in January. And we're always on the—looking at the opportunity for a regulatory reduction, both looking at regulations that are coming down the pike and how do we implement those and work with the administration to implement those in a way that is as least disruptive and burdensome to both patients and physicians, but also issues like prior authorization, other utilization management techniques that are perennial issues for us that we will continue to hammer away at. 

We've made some progress over the last few years. We have some allies, both in Congress and the administration, to make continued progress on those. And so I think we'll have a lot of discussion about that. But certainly, I think the impact of this legislation and what it's going to have on the health care system is, and it should be, a major topic of consideration as we work our way forward, both during the interim meeting and in the months, and quite frankly, in this bill, the years to come. 

Dr. Aizuss: So we have a question from someone here about—who's a—who lives in a rural area where there's a severe physician shortage and hospitals are closing. And given the fact that there's a $50 billion allocation for rural health care—and we don't know how that's going to be divided, whether it's $1 billion per state or some other competitive process. That doesn't seem clear based on the complexity of the application. How do you think this bill is going to impact the physician shortage and closure of hospitals in rural areas? 

Askew: So half the money will be distributed to states equally. All 50 states applied. And so it will be half-developed over five years—so basically, $1 billion a year for—well, that doesn't quite work out—half a billion dollars a year for each state over the next five years to apply to the different projects that they have put forward. And then the other half will be—a grant will be awarded to states based on applications and specific issues that they would like to tackle. There's a whole complicated scoring system. 

And yes, $50 billion is a lot of money. But this is in face of what is projected to be $1 trillion in cuts. So we don't need to minimize the fact—or don't need to overstate the fact that $50 billion is somehow transformative because the negative pressures on hospital finances, physician finances, finances across the health care system because of this bill are going to be tremendous. 

And so whether it's hospitals closing or physician practices struggling because of increased burden of seeing patients who no longer have coverage, this is going to be a very difficult period. That's why it's so important that we do everything we can to mitigate it. 

Congress did not cut $1 trillion. Congress put forward a set of policies that are projected to reduce spending by $1 trillion. We have that opportunity to try and not let that happen, to try and not let those reductions come into place. And so that's why we need to continue to talk about this every day. 

But I was on the phone with one of the large hospital associations just today. And they are extremely concerned, as they should be, about the impact that some of this legislation is going to have. But they, I think, are in the same place we are. This is a couple of years in rolling out. We have opportunities to mitigate it. And so we need to be about doing that. 

Dr. Aizuss: So one more audience question is that many premature newborns are born to parents without insurance. Infants are eligible to obtain Medicaid to cover their hospital bills. Will this be impacted under the OBBA? 

Askew: So I may need to turn to Annalia for this. But most of the cuts are to the expansion populations. I think most of the infants that are currently born into and covered by Medicaid would not be affected. But Annalia, let me ask you to weigh in on that. 

Michelman: Yeah, that's exactly right. Medicaid coverage for what we call deemed newborns is a mandatory coverage group that—there's also mandatory coverage for low-income kids, pregnant women, people with disabilities. And those mandatory categories are not targeted by this bill. The eligibility is not affected. 

But I don't think that's all good news because I think that there's still really a concern about the spillover effect here that when Medicaid budgets shrink, even though states won't be able to touch those mandatory eligibility groups, they can and often do cut reimbursement rates or some of the supports, administrative supports, that affect everybody's ability to use their coverage. 

So that means that even when somebody is going to be able to maintain their coverage on paper, like the deemed newborns, they might find it more difficult to get care. Hospitals might be forced to close their obstetric or their pediatric units. The nursing homes might need to stop accepting Medicaid. Mental health providers might stop accepting Medicaid. And these effects are going to be really pronounced in the underserved areas, in the rural areas where Medicaid is the dominant payer. 

And so that's really why we're focusing our implementation work on both preserving coverage and protecting access. I think that's really important because if nobody's accepting Medicaid or if all the hospitals have closed and you have to travel too far to access care, then the coverage is kind of meaningless if patients really can't access the care that they need. 

Dr. Aizuss: Well, I want to thank you all for this incredible webinar today. Thank you to the audience for your questions. And thank you to our panelists. 

It's 9:30 on the East Coast, and it's dinnertime on the West Coast. So I want to invite everyone to please join us for future AMA Advocacy Insight webinars. We will take you inside the most important policy issues that are impacting physicians, patients, our health care system. 

We have our work cut out for us this coming year. I'm looking forward to seeing some of our most active members at the AMA House of Delegates next week. Others, hopefully, will attend the State Advocacy Conference in January, and others the National Advocacy Conference in February. And I just want to wish everyone a good night. And thank you, again, for participating. 

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.