Health Access at Risk: Analyzing the One Big Beautiful Bill Act and Its Impact During Disasters

1. Disproportionate Medicaid Strain on Rural and Vulnerable Areas

• Texas has seen more than 20 rural hospital closures since 2010. Under OBBBA, Medicaid reimbursement cuts could reach nearly $70 billion under the House bill and $1 trillion under Senate versions, prompting concern about systemwide impacts. While that figure comes from advocacy-oriented projections, it reflects a growing concern among hospital associations.

• Many rural communities lack alternative healthcare infrastructure. Evidence from Trinity County, Texas, shows how even a single hospital closure can disrupt emergency response and place lives at risk. This disruption significantly affects ambulance response times, specialty care access, and ongoing treatment for chronic illnesses, as shown by increased EMS transport and activation times following rural hospital closures.

• In Virginia, 336 rural hospitals face operational risk, including six critical facilities. These figures reflect modeling from hospital associations and are not confirmed closures but signal potential pressure points.

Disaster Insight: Closing rural hospitals reduces surge capacity, delays treatment, and affects outcomes during emergencies like hurricanes and wildfires. These risks increase when local systems have no financial buffer.

2. Work Requirements and Disruption in Healthcare Continuity

• OBBBA mandates 80 hours per month of work, volunteering, or education for Medicaid recipients, alongside new mid-year eligibility checks set to begin in 2027.

• States may suspend these requirements under emergency conditions using Section 1135 waivers, though these waivers are time-limited and subject to federal approval.

• A Commonwealth Fund analysis finds that administrative complexities tied to work mandates frequently lead to disenrollment among eligible individuals, without consistent employment gains.

Disaster Insight: Medicaid coverage loss during a crisis may prevent families from accessing essential care, delaying evacuation services, prescriptions, or behavioral health support.

3. Marketplace and ACA Subsidy Erosion

• The American Hospital Association projects that ACA marketplace changes could result in up to three million people losing coverage. While this estimate is directional, it highlights concerns from provider groups.

• The Congressional Budget Office estimates between 10.9 and 16 million Americans could lose coverage by 2034 due to Medicaid changes and reduced subsidies. This is one of the few nonpartisan sources cited and strengthens the report’s credibility.

• A KFF policy brief underscores the role of Medicaid and ACA subsidies in maintaining coverage during national crises and highlights the potential for major losses in states with weak safety nets.

Disaster Insight: Declines in insurance coverage affect preventive care access and surge capacity. Hospitals may be forced to shift limited resources away from acute crisis response.

4. Partial Rural Bailout Insufficiency

• A last-minute provision included $10 billion annually for five years to support rural hospitals. While meaningful, it is not clear that this funding offsets longer-term reductions.

• Critics argue that rural providers need consistent, flexible support, not episodic appropriations. Proponents counter that this is the largest rural health investment in decades.

• A GAO report on rural health infrastructure notes that capital infusions, while helpful, are not a substitute for sustained reimbursement or targeted operational supports.

Disaster Insight: A static appropriation model may not keep pace with year-to-year volatility in public health threats, especially for smaller systems.

5. Human Toll and Emergency Resilience

• A Senate health policy report estimated that over 50,000 excess deaths annually could result from coverage loss and reduced care access. While impactful, this figure is based on extrapolation from ACA repeal models and is not a CBO estimate.

• Business Insider reports that OBBBA includes approximately $1 trillion in Medicaid cuts over the next decade, with federal funding declines ranging from 6 to 21 percent across states. The analysis highlights that rural hospitals, already under financial strain, are among those most likely to be impacted.

Disaster Insight: Communities with limited coverage and fragile provider networks experience slower recoveries and higher disaster-related mortality.

6. Strategic and Policy Recommendations

• Targeted Medicaid Stabilization: Ensure emergency protections extend beyond short-term allocations.

• Administrative Flexibility: Streamline enrollment during and after disasters using existing waiver authorities.

• Incentivized Readiness Funding: Tie grantmaking to preparedness benchmarks and continuity plans.

• Disaster-Specific Carve-Outs: Exempt critical health services from redetermination or coverage disruptions.

• Investment in Preventive Care: Improve resilience by funding community health, especially in high-risk regions.

7. Conclusion

The One Big Beautiful Bill Act introduces substantial changes to federal health funding with far-reaching implications. While the legislation advances a vision of cost containment and program reform, it also shifts risks to local systems and may reduce flexibility in moments of crisis.

For rural hospitals, low-income families, and disaster-prone communities, the stakes are high. Even with new investments, the structural tradeoffs in OBBBA warrant close monitoring to ensure that emergency preparedness and equitable access remain viable priorities.