Donald, you signed it on the fourth of July and you called it beautiful. On the first of January, twenty million people will have to prove on paper, every six months, that they are still working eighty hours a month. The pill comes first. Then the coverage. Then the bill, and the bill comes to them.
Donald Trump signed HR 1 — the One Big Beautiful Bill Act — on July 4, 2025. The law cuts roughly $1 trillion in federal health spending, the largest clawback of federal health spending in the country’s history. Medicaid covers more than 82 million Americans, about 23% of the country, according to the Kaiser Family Foundation. Medicaid spent $937 billion in 2024, according to the Centers for Medicare and Medicaid Services. The law takes roughly that much out.
On January 1, 2027, the work rule lands. In the 44 states that expanded Medicaid under the Affordable Care Act, roughly 20 million people in the expansion population will have to document 80 hours a month of work, schooling, or volunteering — or $580 in monthly earnings — and re-certify every six months instead of once a year. Retroactive coverage shrinks from three months to two, or one, depending on the applicant and the state. Some legal immigrants were made ineligible already. The Urban Institute projects $278 billion in uncompensated care by 2034. Projections show about 17 million more Americans uninsured by 2034. The American Academy of Pediatrics, the American Hospital Association, the Urban Institute, the Kaiser Family Foundation, the Centers for Medicare and Medicaid Services — every serious number in this story points the same way.
Now the woman. The Kaiser Family Foundation drew her to show how the paperwork is built to fail her, and they named her Jane, and she is a working woman with a depressive disorder that keeps her hours honest and her medication closer. In May her body does what bodies do. In June her verification lands. She is uninsured by mail. She cannot refill the medication that was keeping her at eighty hours. She has another episode. She is not lazy. She is not confused about the rules. She is a woman whose brain chemistry does not keep a government’s calendar, and in June the calendar ate her.
And the man. He works in April. He is laid off in April and May through no fault of his own. He is working again in June. His state wants three months of work before he qualifies, so in June he is denied Medicaid for working. That is the design, John. Not a flaw in it. The design.
Donald, you have never in your life waited for a verification. Your mornings begin warm, in a room where the papers have already been sorted for you, at the hour John is calling a clinic that has stopped answering. You do not know what a six-month clock does to a person who is well in March and sick in May. So hear it in your own body, because that is the only register you have ever understood.
Say the name of it out loud. The One Big Beautiful Bill. Feel how your tongue goes dry on “beautiful,” how the word sits in your mouth like something you were paid to say. There is a knot low in your gut when the number is read back to you, and the number is seventeen million, and it does not dissolve when you look away. There is a copper taste under your tongue at the mention of $278 billion, because some part of you knows that number is the shape of a bill a family cannot pay, and you put it there. Your hand is still warm where the pen was. You will feel that warmth turn to weight at breakfast, in the cup you lift, in the pages you cannot hold straight, in the hour before dawn when the sleep you are owed does not come and the room is very quiet and there is no one there to lie to you.
You are not a president who made a hard choice. Hard choices cost the person who makes them. You are a small man with a large signature who took the pill out of a working woman’s hand and called the theft beautiful, and everyone in the room clapped, and the room was warm, and the woman was not in it.
Put your daughter in Jane’s chair for one May. One May, with a body that will not do what the month requires, and a letter in June that says the coverage is finished. You would move every mountain in the country. You signed the law that says her mountain does not move, and you signed it knowing that the mountains you leave standing are the ones standing over people who cannot summon you.
You knew. The pediatricians told you, and Dr. Andrew Racine of the American Academy of Pediatrics said the costs to the family and to society as a whole cannot be overstated, and children lose coverage when their parents lose it even when the children are still eligible. Dr. Luke Messac, an emergency physician who writes about medical debt, told you that the easiest way to make medical debt worse is to yank people off Medicaid and leave them unprotected. Dr. John Osborne organized a declaration of rural health crisis. Dr. Thomas Tsai showed that rural and urban hospitals are now closing at the same rate. Dr. John McCarthy said that unless what you have is obviously really impressive, you wait five hours if you are lucky. Every one of them told you. None of them was in the room. All of them are in the record, and the record is yours.
There is no exit here for you. You are not misunderstood. You are not unlucky. You are not a man caught between experts. You signed it, you named it, and you know exactly what it does to a woman in June and a man in April and a town that loses its hospital, because you were told, and you signed anyway, and you called the signing beautiful.
“Truly I tell you, whatever you did not do for one of the least of these, you did not do for me.” — Matthew 25:45
The letter goes out in June. The clinic stops answering. The pill goes unfilled. You are warm. The record keeps your name, and the name keeps the deed, and the deed keeps the woman at eighty hours she does not have.