Trump Obamacare Changes: Requirements and Coverage

Under the One Big Beautiful Act, sweeping reductions to Medicaid and modifications to Affordable Care Act enrollment rules have been enacted. The alterations promise to reshape federal healthcare requirements and change who qualifies for coverage. These shifts could impact millions of Americans, especially those in affordable care markets. Here’s what’s changing and how it may affect your access to care, costs and eligibility. 

A financial advisor can also help you evaluate your options, navigate marketplace decisions and adjust your financial plan accordingly.

• The One Big Beautiful Act slashes more than $1 trillion from Medicaid over the next decade, with up to 12 million Americans¹ at risk of losing coverage, particularly in rural areas.
• Beginning in 2026–2027, certain adults will face new requirements — like working or community engagement — and frequent income verification, which may result in numerous coverage losses. 
• Open enrollment periods are shortened through 2027, automatic re-enrollment eliminated and stricter eligibility checks introduced, raising the risk of gaps in private insurance coverage. 
• The rollback of enhanced premium tax credits and tightened cost-sharing subsidies could lead to premium spikes of up to 75%, increasing financial burden on ACA enrollees. 

The One Big Beautiful Act marks the most substantial overhaul of Medicaid and ACA regulations since their inception, cutting nearly $1 trillion in federal healthcare spending over the next decade and introducing sweeping new eligibility requirements. 

Among its most impactful changes are significant reductions in Medicaid funding through provider tax caps, reduced federal matching payments and tighter state-level funding tools. 

The law also reverses emergency-era ACA improvements by ending enhanced premium tax credits and scaling back cost-sharing subsidies², which are expected to raise marketplace premiums as early as 2026. 

While many provisions take effect immediately, the most stringent Medicaid reforms, such as community-engagement work requirements and biannual eligibility confirmations³, are scheduled to begin between 2026 and 2027. 

Beginning in late 2026, able-bodied adults between the ages of 19 and 64 enrolled in Medicaid expansion programs will be required to complete at least 80 hours per month of community engagement to maintain their coverage. These include employment, volunteering or educational activities.

In addition, the legislation introduces stricter eligibility procedures. These include biannual renewal requirements and more rigorous income documentation. The changes may make it harder to stay enrolled without interruption. 

Combined, the changes could lead to millions of Americans losing Medicaid coverage by the mid-2030s, particularly in states with expanded Medicaid programs. 

Individuals enrolled in ACA Marketplace plans will also face significant changes. 

The open enrollment period will be shortened, ending on December 15 instead of extending into mid-January, which may make it harder for some to enroll in time.⁴ 

Applicants will encounter mandatory eligibility checks for income, residency and immigration status before subsidies are approved, adding an extra layer of verification to the process. 

Additionally, starting in 2027, automatic re-enrollment will be eliminated entirely, requiring enrollees to reapply and verify their eligibility annually to maintain their coverage. 

The rollback of enhanced premium tax credits, introduced during the pandemic, will drive up marketplace premiums beginning next year. Without these expanded subsidies, some enrollees could see their premiums rise by as much as 75%⁵. 

The bill does reinstate cost-sharing reduction (CSR) payments to help lower out-of-pocket expenses. However, it also excludes coverage for abortion services and introduces new premiums even for those enrolled in bronze or catastrophic plans.