This is Part 1 of a two-part series on the Big ‘Ugly’ Bill: This part covers Medicare and Medicaid impacts

When the “One Big Beautiful Bill (OBBB) Act” was signed into law on July 4, 2025, it came with full and complete support from North Dakota’s Republican congressional delegation U.S. Rep. Julie Fedorchak, U.S. Sen. Kevin Cramer, and U.S. Sen. John Hoeven.

Fedorchak, Cramer, and Hoeven, like all their other Republican counterparts, are betraying the middle class and raising costs on American families with the One Big Beautiful (Ugly) Bill. Why? So Americans can foot the bill for giveaways to Trump’s billionaire donors.

Here are vital notes about and harmful impacts on Medicare and Medicaid from Fedorchak’s, Cramer’s, and Hoeven’s support of the One Big Beautiful (Ugly) Bill Act:

Medicare:

• 68 million people are insured through Medicare (65 or older and people with certain disabilities).
• Congressional Budget Office (CBO) estimates that Medicare will be cut by $45 billion in 2026, with cuts totaling $490 billion by 2034. Some of the cuts are the result of a trap set by the Pay-As-You-Go Act of 2010, which will trigger automatic spending cuts.

Medicaid:

• Medicaid is a state-federal partnership, funded jointly with state funds and matching federal funds. 72 million Americans, or 1 in 5, are insured through Medicaid. Nearly 6 million Americans are insured through the Children’s Health Insurance Program (CHIP).
• Medicaid and CHIP cover nearly 78 million Americans, including children, pregnant women, parents, seniors, and individuals with disabilities.
• Some states also cover some community- and home-based services (including North Dakota), often more popular and more cost-effective than institutional care.
• CBO estimates that the OBBB ACT will cause 10 million people to lose healthcare coverage by 2034 as a result of changes to Medicaid.
• 92% of Medicaid Adults in 2023 were working full- or part-time (64%), or not working due to caregiving responsibilities, illness or disability, or school attendance. The remaining 8% of Medicaid adults reported that they are retired, unable to find work, or not working for another reason. Factors such as health status, age, education, and dependent care responsibilities all affect whether or not a Medicaid adult is working. Personal disabilities or other functional limitations also can reduce participation in work.
• Even for those who meet the work requirement, the stricter reporting requirements will cause some to lose coverage.
• Funding for Medicaid comes from state and federal sources, with the federal funds matching the state funds at a rate of 50-77% per Medicaid enrollee and 90% per Medicaid Expansion enrollee (the Affordable Care Act). Most states raise some of that state funding through taxes on hospitals and other healthcare providers (called provider taxes). The OBBB ACT limits and reduces the amount states can raise in this way, thereby reducing the federal matching funds.
• Financial assistance to help people afford ACA insurance will expire at the end of 2025, causing an estimated 5 million more people to lose insurance.

Key Quotes:

“Healthcare is a human right but also a patriotic imperative. We are a stronger nation when we are healthy. Regular health checks and early intervention require healthcare coverage.”

“Bobby Kogan, Center for American Progress, calls the One Big Beautiful Bill Act ‘The largest redistribution from poor to rich in a single bill in American history.’ The bill is regressive, with higher tax rates for low-income people.”

“The Republicans claim they won’t touch Medicare and Medicaid, but this strategy seems like death by a thousand policy cuts.”

“When taken together with cuts to SNAP, social programs, community services, and Public Broadcasting, these changes to Medicaid and Medicare will make America sicker, hungrier, lonelier, and poorer. All to fund extending tax cuts for the super wealthy.”

Timeline for Implementation:

Immediately:

• Rule change makes it more difficult to enroll in Medicaid’s Medicare Savings Account.
• Rule change makes it harder to enroll in Medicaid, CHIP, and Basic Health Program.
• Rule change eliminates the requirement that nursing homes have adequate staffing to protect health and safety of residents.
• Cancellation of enhanced premium tax credits raises ACA premiums for next plan year, affecting 20 million enrollees, starting Nov 1.

After the 2026 midterm elections:

• On January 1, 2027, OBBB Act adds work reporting requirements for those covered by Medicaid Expansion. Even though most people on Medicaid already work or are exempt for accepted reasons, the complications of reporting may cause many to lose coverage.
• Also on January 1, 2027, OBBB ACT reduces retroactive Medicaid coverage (from 3 months to 1 for Medicaid Expansion and 3 months to 2 for traditional Medicaid).
• Also on January 1, 2027, the requirement for proof of eligibility for Medicaid Expansion enrollees will increase to twice a year. These redetermination requirements are likely to increase the number of people whose coverage lapses.
• OBBB Act reduces the number of noncitizens eligible for Medicaid by restricting the definition of qualified immigrants, removing refugees, asylees, and humanitarian parolees.

Long-Term Changes:

• OBBB ACT limits how states can gather provider taxes to fund Medicaid costs and gain matching federal funds.
• With fewer federal funds, states may be forced to cut optional services like Home- and Community-Based Services, a loss of services that could force more people into nursing home care. HCBS is more cost effective and often preferred by people.
• Funding cuts will hit rural hospitals particularly hard, putting many at risk.
• January 4, 2027, eliminates some Medicare coverage for some legal immigrants.
• January 1, 2028, fewer drugs will be eligible for Medicare drug price negotiation.
• October 1, 2028, OBBB Act requires states to impose cost-sharing requirements for Medicaid Expansion enrollees with incomes above 100 percent of federal poverty level.

North Dakota Specific Information:

• 147,000 people in North Dakota are insured through Medicare, mostly those who are 65+.
• North Dakota receives about $972 million annually for Medicaid. This is 37% of the federal funds sent to the state.

Who is enrolled in Medicaid in ND:

• 41% children (ages 0-18)
• 41% adults (ages 19-64) (92% of these being full-time or part-time workers)
• 8% seniors (ages 65+)
• 10% persons with disabilities (all ages)

Who gets Medicaid money in ND:

• 12% to children (ages 0-18)
• 33% to adults (ages 19-64)
• 25% to seniors (ages 65+)
• 30% to persons with disabilities (all ages)

In North Dakota:

• Medicaid pays for 23% of births in ND (including access to critical prenatal care, maternity care, and postpartum services)
• Medicaid covers 23% of all ND children (insures those in low-income families, those with special healthcare needs, and those in foster care)
• Medicaid pays for the care of 53% of nursing home residents in ND (critical nursing home and community-based services for seniors and people with disabilities)
• Medicaid covers mental health services in ND (nationally, Medicaid is the largest single source of funding for mental health and substance use care)

Georgetown University found that cuts would:

• Do nothing to lower healthcare costs or improve quality and access to care
• Devastate state budgets, putting other priorities like K-12 funding at risk
• Undermine financial stability of the health system, especially rural hospitals and community clinics.
• Jeopardize health coverage for millions of children and families, seniors, and people with disabilities.

Closing Statement:

“This is all part of a larger package of sweeping cuts, changes, and new programs. In the period from 2025-2035, the deficit will still continue to increase by an estimated $3.4 trillion, all to fund tax cuts mostly for the super wealthy.”

Sources:

Georgetown University McCourt School of Public Policy Center for Children and Families • League of Women Voters • Kaiser Family Foundation • Center for American Progress • Congressional Budget Office