House Republicans have made substantial changes to the Medicaid portion of their major legislative proposal, aiming to appease hard-liners within their party. The amendments, released in late May 2025, include accelerating work requirements for Medicaid recipients and modifying state-level criteria for eligibility. By moving the start date of these requirements from 2029 to 2026, the GOP seeks to align with conservative priorities while attempting to balance the needs of moderates who have expressed concern over the potential impact on coverage.
These changes could lead to significant cost savings for the federal government, with estimates suggesting tens of billions in additional savings due to the earlier implementation. However, critics warn that this acceleration may also result in more people losing their Medicaid coverage, particularly those who are low-income and vulnerable. The Congressional Budget Office previously estimated that a similar policy could cause 7.6 million Medicaid recipients to become uninsured, with millions more losing coverage under the Affordable Care Act.
While the bill avoids some of the most contentious provisions pushed by hard-liners — including those that would alter federal spending shares in Medicaid — it introduces other changes that could have broad implications. For example, the new criteria for losing federal Medicaid funds would apply to states that offer coverage to undocumented individuals, a move likely aimed at encouraging states to limit such coverage. Additionally, the revisions prohibit coverage for adults in the program for gender-affirming care, expanding previous restrictions that only applied to minors.
The amendments are part of a broader effort to secure support from conservative factions within the House, particularly Rep. Chip Roy of Texas, who pushed for the changes during a White House meeting with former President Donald Trump. The GOP leadership, led by Speaker Mike Johnson, has made clear that the bill will not include changes to the Medicaid state provider tax, which has been a point of contention among moderates. Despite these concessions, the bill does include provisions to fund cost-sharing reduction payments to insurers on Obamacare’s exchanges, bringing back a policy abandoned by Trump in his first term but potentially offering substantial cost savings.
Hard-liners are likely to use the accelerated work requirements, the expanded criteria for losing funds, and the changes to the clean-energy tax credits as key selling points to rally support within their ranks. While moderates remain cautious, the broader financial impact of the bill has been estimated to save nearly a trillion dollars over a decade, highlighting the significant economic stakes at play in this legislative battle.