The long-term effects of the One Big, Beautiful Bill Act—called OBBBA, or H.R. 1, for short—continue to unfold for the nation’s patients and physicians, with two significant changes happening this month.
“When Congress was debating this bill, the AMA raised concerns that it would make it harder for patients to access care and could lead to worse health outcomes,” said AMA President Willie Underwood III, MD, MSc, MPH. “Now that these policies are taking effect, our focus is on helping patients understand what is changing and what they can do to maintain coverage. We hope these resources help patients and physicians navigate the transition, and we are ready to work with Congress and the administration to protect patients’ access to care.”
The AMA also advocated against provisions that will severely cut funding for federal health programs and restrict access to health coverage. A wealth of evidence shows that patients who are uninsured live sicker and die younger.
H.R. 1’s wide array of changes to Medicaid, the Affordable Care Act (ACA) and other aspects of the nation’s health system take place over an implementation timeline that stretches many years (PDF). Several provisions took effect when the law was enacted in July 2025, followed by a series of provisions that took effect in January 2026. October marks another milestone in how this significant shakeup of American healthcare is rolling out.
More changes in Medicaid eligibility
One of the big shifts happening in October is implementation of an H.R. 1 provision that narrows which non-U.S. citizens may be covered by Medicaid or the Children’s Health Insurance Program (CHIP).
The law generally limits full Medicaid or CHIP eligibility to lawful permanent residents, certain Cuban and Haitian immigrants, citizens of the Freely Associated States (COFA migrants) lawfully residing in the U.S., and lawfully residing children and pregnant adults in states that cover them under the Immigrant Children’s Health Improvement Act.
This means that refugees, asylees, Temporary Protected Status (TPS) holders, parolees and other lawfully present noncitizens will no longer be eligible for full coverage. Some states may continue coverage using state-only funds, and emergency Medicaid remains available for treatment of emergency medical conditions for individuals who otherwise meet Medicaid eligibility rules, but for their immigration status.
It’s worth noting that, prior to passage and enactment of H.R. 1, federal payment for Medicaid coverage of noncitizens who are not lawfully present has long been prohibited—except for treatment of emergency medical conditions.
Already in January, under H.R. 1 lawfully present noncitizens with income below the federal poverty line lost help paying for ACA Marketplace plans (aka “premium tax credits”), including for lawfully present permanent residents subject to the five-year waiting period. People affected by this provision can still buy a Marketplace plan but must pay the full premium.
Explore further with guidance from the AMA on changes to Medicaid, Medicare and ACA Marketplace coverage for non-U.S. citizens (PDF).
Shifts in federal match for Medicaid and SNAP
How much the federal government contributes to fund Medicaid—a federal-state program—is determined by Federal Medical Assistance Percentage (FMAP). Another big change taking effect this month under H.R. 1 relates to the FMAP that applies to emergency Medicaid services provided to certain noncitizens.
Beginning Oct. 1, federal reimbursement for emergency Medicaid services provided to noncitizens who are ineligible for Medicaid due to their immigration status is limited to the state’s regular FMAP. The enhanced 90 percent federal match for the Medicaid expansion no longer applies to emergency Medicaid, even when a person would otherwise be eligible under a Medicaid expansion program.
This is expected to reduce even further the federal government’s support for Medicaid programs, shifting even more of those costs to states, increasing financial pressure on hospitals, and further straining the nation’s healthcare safety net.
Also taking effect this month is another H.R. 1 provision that affects administrative cost-sharing in the Supplemental Nutrition Assistance Program (SNAP). This element of the law cuts the federal share of SNAP administrative costs from 50% to 25%. The Congressional Budget Office has estimated that this will reduce federal spending by nearly $25 billion over the next decade.
AMA advocacy on H.R. 1
The AMA has been deeply engaged on H.R. 1, including recently urging the Centers for Medicare & Medicaid Services (CMS) to revise its work-requirement rules to protect patients with serious health conditions, preserve state flexibility in determining medical frailty exemptions, and reduce administrative burdens that could cause eligible patients to lose coverage.
In September, the AMA, Massachusetts Medical Society and nine national medical specialty societies filed an amicus brief (PDF) supporting 25 states and the District of Columbia challenging key provisions of the CMS interim final rule implementing new Medicaid work requirements.
In July, the AMA submitted comments (PDF) in response to a CMS interim final rule implementing the work requirements mandated by H.R. 1. The comments emphasize AMA's concerns with the rule's unduly burdensome requirements, especially with respect to medical frailty exemption standards.
Dive deeper with this AMA Advocacy Insights webinar on H.R. 1, how it is affecting patients and physicians and what states can do to mitigate its impact.
