How Trump's 'Big, Beautiful Bill' affects Tennessee Medicaid

President Donald Trump's "One Big Beautiful Bill Act" was signed into law earlier this month.The 940-page bill provides sweeping changes to a variety of government programs, including Medicaid, the Supplemental Nutrition Assistance Program and others.The bill has been largely touted by the Trump administration as a groundbreaking tax cut for middle and working-class people. The administration points to the Medicaid and SNAP cuts as elimination of "waste, fraud and abuse," one of President Trump's key policy goals in his second presidential term.However, others say the bill will have the exact opposite effect. The Congressional Budget Office (CBO), a nonpartisan organization that advises Congress on fiscal issues, reported in June that the bill would benefit middle and upper-class Americans while reducing the incomes of poorer Americans.In Northeast Tennessee, median household incomes in Sullivan, Washington, Unicoi, Carter and Johnson counties are all well below state and national statistics. In Carter County, median household incomes are more than $30,000 under national figures.As such, if the One Big, Beautiful Bill Act does end up disproportionately affecting lower-income families, it's likely to be felt more directly by Northeast Tennesseans.Here is a look at some of the most impactful provisions in the newly passed legislation.Medicaid cuts affect TennesseeAbout 10 million people nationwide will lose health insurance coverage in the next decade under the new law, according to the CBO.Based on the first House version of the bill, the nonprofit formerly known as the Kaiser Family Foundation (KFF) estimated that about 110,000 people would lose coverage in Tennessee. About 40% of this population would be impacted by changes to Medicaid, while the other 60% would become uninsured due to changes to the Affordable Care Act (ACA).Overall, KFF estimates around a $7 billion decrease in federal Medicaid funding in the state over the next 10 years.The cuts will hit rural areas hard. People in these communities rely on Medicaid more than others, making rural hospitals particularly dependent on reimbursements from the federal program. Nearly half of all rural hospitals already operate with negative margins, so general cuts to Medicaid and taxes that help pay for the program will cause these facilities to pay more for uncompensated services.Michael Meit, director of the ETSU Center for Rural Health and Research, also emphasized that Medicaid helps cover health care services like emergency rooms, substance use treatment and dementia support."Whether you're on Medicaid or not, you probably rely on your local hospital for a lot of services," he said.Rural hospitals face stressTo address concern about the law's impact on rural hospitals, federal legislators created a "Rural Health Transformation Program" that will allot $50 billion over five years for states to improve rural health care.Experts say it's not enough.KFF estimates that the law will reduce federal Medicaid spending in rural areas by $155 billion over 10 years, including an estimated $2.24 billion reduction in rural Tennessee. As it stands, the rural health fund makes up only a fraction of that loss."Right there, you've made up a third of it, and only for five years," Meit said. "What happens after the five years?"Policy groups also express concern about the program's distribution system, which will seemingly split $25 billion evenly across states. This could mean that Tennessee — which has about 65 rural hospitals — could receive the same amount of funding as a state like Vermont, which has five.The other half of the fund will go toward rural health initiatives, which could apply to programs outside of hospitals.Tennessee is already infamous for its rural hospital closures — according to a 2019 report from the Tennessee Health Care Campaign, a nonprofit health care advocacy group, the state has the most closures per capita in the nation.In the largely rural region of Northeast Tennessee, Ballad Health has expressed ample concern about the new law's impact on its services. Chairman and Chief Executive Officer Alan Levine wrote on X that the law may delay the Unicoi County replacement hospital. The facility, along with eight others in Tennessee, is also noted as an at-risk hospital in a letter from Democratic senators.Meit said there's still time for Congress to address these cuts to rural health care."We are still in the budget negotiations," he said. "I think that people need to look at whether that $50 billion is going to address the need, and whether we need to add funding into the federal budget."Meit added that everyone should care about cuts to rural health because the nation's food, energy and military security all come from the rural parts of the country."If we do not find ways to sustain the health and well-being of our rural communities, it is a national security risk," he said.Obamacare changes increase premiumsThe expiration of tax credits for ACA health plans will also increase coverage costs for certain insurances, possibly pricing some people out. The credits help cover health insurance premiums. Since the law does not include a renewal, they are set to expire by 2025 if Congress doesn't take action.Health insurers are requesting the largest premium increases in more than five years, meaning that monthly out-of-pocket rates for people covered under those plans could increase by more than 75%, according to the Peterson-KFF Health System Tracker.Although the tracker analysis does not include responses from Tennessee insurers, others across the U.S. cite the tax credit expiration and rising health care costs as the main justifications for increasing costs. Rate changes will finalize in several months.Work requirements have minimal impactWork requirements will only be implemented in states which have expanded Medicaid through the Affordable Care Act.Tennessee is one of 10 states which have not expanded Medicaid. Gordon Bonnyman, co-founder of the Tennessee Justice Center, said that means the work requirements implemented through the One Big Beautiful Bill Act will likely not affect Tennesseans.Recipients of Medicaid expansion in nearby states such as Virginia and North Carolina, however, will be required to prove they have worked 80 hours in the past month or have earned the equivalent of $580 in the same time period.Community service, job training, work programs and half-time attendance at a school can also count toward work requirements, while certain groups are completely exempted from the requirements.Work requirements for these states will go into effect by January 2027, although states have the option to begin some requirements sooner through 1115 waivers. As of July 22, 14 states have initiated the process to do so, but Tennessee is not one of them.Bonnyman says it is possible the state could use these waivers to implement work requirements on non-expansion adults, but that it is unlikely."But we don't know what the state's intention is," he said.The CBO estimated that the work requirement provisions alone will account for a $344 billion reduction in federal spending over the next 10 years, while increasing the number of Americans without health insurance by 4.8 million.Legal immigrants lose coverageEffective October 2026, some legally-present immigrants will also lose Medicaid coverage.The new legislation specifies that only certain legally-present immigrants will be eligible to receive Medicaid, including: lawful permanent residents; certain Cuban and Haitian immigrants; COFA migrants lawfully residing in the U.S.; and U.S. nationals.The new legislation eliminates eligibility criteria for refugees; individuals granted parole for a year; individuals granted asylum or similar relief; and certain victims of abuse and trafficking.Currently, undocumented immigrants are not eligible for Medicaid coverage in Tennessee.Some copays increaseStarting October 2028, certain adults enrolled in the Medicaid expansion program will pay higher out-of-pocket costs for non-primary visits such as procedures, treatments and specialist visits.As a non-Medicaid expansion state, this does not include Tennessee, said Bonnyman. Preventive care—including services such as checkups, shots and prenatal care—is free under TennCare rules.TennCare currently requires copayments on pharmacy visits, and households above 133% of the federal poverty line could be subject to copayments for visits to specialists, the emergency room and inpatient hospital admissions.In other states, enrollees with household incomes between 100% and 138% of the federal poverty line will be subject to copayments up to $35 a visit for certain visits. States have the option to charge less.Primary care, mental health treatment, substance use treatments, family planning, emergency care and institutional long-term care will be exempt from these copayments.Other provisions in the 'One, Big, Beautiful Bill Act'Changes to health care are only a fraction of the provisions present in the new legislation.The bill includes cuts to benefits for Supplemental Nutrition Assistance Program (SNAP/food stamps) recipients. The CBO estimated that 3.2 million people under 65 will lose SNAP benefits as a result of the bill.The bill also alleviates federal taxes on tips and overtime pay for two years, while implementing tax cuts on social security wages. Both provisions were primary sticking points during President Trump's second-term campaign.In addition, there are some more obscure provisions, such as a $200 increase to the child tax credit, previously worth $2,000, and an extension of a previous law which gave tax credits to businesses to provide paid leave for their workers.The One Big Beautiful Bill Act is likely to be a primary talking point for both Democrats and Republicans in the 2026 midterm elections, with the former lambasting the legislation for hurting working families while the latter heralds it as the "most pro-family legislation in history."InsideA column by Alan Levine, chairman and CEO of Ballad Health, writes an article about possible affects of the "One Big Beautiful Bill." See A4.