Opinion: Medicaid changes in the federal 'One Big Beautiful Bill Act' will have the most impact on rural America

President Donald Trump signs the One Big Beautiful Bill into law on July 4. (Photo via MedPage Today)

Despite the numerous taxation and spending changes in the federal budget bill known as the One Big Beautiful Bill Act, its most far-reaching changes may be to federal health care policy and spending. In an opinion piece for MedPage Today, Holland Haynie, M.D., a chief medical officer for a Federally Qualified Health Center serving five rural counties in Missouri, shares what she and other medical stakeholders think the reforms will ultimately mean for the future of health care for rural and underserved patients.

"I spent last weekend reading the bill. I joined a policy call with our state association. I talked to nonprofit partners, pharmacists, and other FQHC leaders. . . . Here's what I learned," Haynie writes. "New provisions either require states to set or give them more flexibility in setting stringent eligibility requirements, tighter enrollment verification, and work requirements."

Additional requirements add a Medicaid coverage hurdle that many people won't be able to overcome. Haynie explains, "In rural and underserved communities, paperwork barriers and access gaps are already steep. The impact may not be immediate, but over time, the shift could mean fewer patients covered and more strain on frontline clinics."

The bill dilutes Medicaid expansion and "states like Missouri, which expanded coverage only fairly recently. . . may now struggle to sustain it," Haynie writes. "When the federal match drops or plateaus and enrollment swells, states will face difficult choices cut benefits, reduce payments, or tighten eligibility."

What could that mean for a rural patients? Haynie gives an example:

"Let me tell you about a patient I saw last week. She's in her 60s. She's working two part-time jobs. She doesn't qualify for Medicaid, doesn't have employer insurance. . . She came into our clinic because she couldn't breathe. . . .We stabilized her. Our nurse followed up. . . . We did everything we could to keep her out of the hospital and in her home. That's what FQHCs do.

"Under this new law, we may not be able to do that much longer as our operating margins get even thinner. Uninsured rates will rise. Clinics will close. Access to care will shrink. And when that happens, the public will ask: how did this happen?"

"If you're in health care -- especially community-based care -- read the bill. Talk to your administrators. Talk to your legislators," Haynie writes, "The 'Big Beautiful Bill' may be remembered for its fiscal policy. But its deepest consequences will be felt in the quiet spaces of rural America: in exam rooms, emergency departments, and pharmacy counters where coverage used to exist."