The ‘One Big Beautiful Bill’ Will Strip Healthcare From Millions—Especially Women and Disabled People

HR 1 was already devastating. Now the Trump administration is making it even worse by narrowing exemptions and expanding Medicaid work requirements beyond what Congress envisioned.

Over 70 million people depend on Medicaid. The Trump administration and members of Congress who constantly turn to the program to make cuts, want you to think that’s a problem. It isn’t—it’s the point.

Every talking point repeated by politicians, amplified by the media and embedded in the rhetoric of those who just voted to gut $1 trillion from the program, is not a policy argument. It’s a cover story. The administration’s story of a typical Medicaid beneficiary is rooted in falsehoods about who is currently supported by the program.

The reality of Medicaid looks like:

… a 59-year-old woman in North Carolina who closed her small business because her eyesight failed, who sorts recyclables at a concert venue when the season allows, who survives on less than $10,000 a year and who relies on Medicaid for arthritis medication and blood pressure care.

Or a 63-year-old woman in Arkansas who spent her career working and now serves as the sole caregiver for her husband with advanced cancer, who is unable to leave him to log the 80 hours a month the federal government will soon demand of her on top of the role she already plays, filling gaps in a system that was already threadbare before it was slashed.

Or a young mom who has been trying for years to find an answer for the rare disease that makes her periodically unable to walk, while struggling to hold down her retail job and care for her kids while waiting months to see specialists.

These are the faces of Medicaid, and this is who HR 1—the so-called One Big Beautiful Bill Act—and the cuts within it, will harm.

And now, with a new interim final rule from the Centers for Medicare and Medicaid Services (CMS), the situation has gotten measurably worse by an administration going further than Congress intended, leaving states scrambling.

The IFR: Going Further Than the Law Requires

Having cancer is not enough. Having HIV is not enough. Having Parkinson’s disease or multiple sclerosis … is not automatically enough.

On June 1, CMS released a nearly 400-page interim final rule that is supposed to tell states how to implement work requirements. Instead, it has sent states back to the drawing board—and will lead to taking healthcare away from even more than the originally estimated 5 million people.

CMS’s change to the medical frailty exemption is the most consequential. Members of Congress claimed this would protect Medicaid “for those who truly need it,” but the interim final rule takes aim at people with medical conditions, going beyond what Congress claimed. Under HR 1, Congress identified people who should be exempt from work requirements because of health status, including who are “medically frail or otherwise have special medical needs.” The interim final rule overrides that approach entirely.

CMS imposes an additional test: To be considered medically frail, a person must demonstrate not only that they have a qualifying condition, but that the condition “significantly impairs” their ability to satisfy the 80-hour work requirement.

Having cancer is not enough. Having HIV is not enough. Having Parkinson’s disease or multiple sclerosis or a serious mental health condition is not automatically enough. Every individual must prove not just that they are sick, but that being sick prevents them from working—a distinction that requires ongoing medical documentation, physician involvement and system capacity that does not yet exist.

The rule also sharply limits self-attestation. Starting in 2028, a person can self-declare medical frailty only once during an enrollment period. After that, they must provide documentation. For people with rare diseases, fluctuating conditions, episodic illness or limited access to consistent medical care, this creates a trap: The system demands the very stability their condition does not allow.

Who Gets Left Behind

The populations most harmed by this policy design are not abstractions. They are the people Caring Across Generations has organized with and heard from for years.

People with disabilities, rare diseases and chronic illness face a particularly cruel catch. Many live with conditions that are real, serious, and work-limiting, but that don’t appear in the datasets states are told to check. Conditions that fluctuate, that worsen under stress, that require specialized clinical documentation to establish severity, are poorly served by automated eligibility systems. People with disabilities who receive care at home through Medicaid may lose their very independence.

Women carry a disproportionate share of this burden. Medicaid is the only public insurance that covers a meaningful portion of reproductive health care, and women rely on it during childbearing years. Medicaid expansion significantly reduces maternal mortality for Black women, and this rule threatens that progress. Women are the backbone of our informal care economy. They are more likely to reduce paid work hours, leave the workforce, or work part-time because they are caring for children, aging parents, or disabled family members.

Family caregivers are supposed to be exempt from work requirements under HR 1 — but that exemption is narrow and verification is nearly impossible to automate. Caregivers who provide informal support to an older adult, a neighbor, or a family member with a disability, without a formal diagnosis on file, without hours logged or a care agency issuing paystubs, will have no easy way to prove they qualify. At least 13 percent of family caregivers rely on Medicaid for their own coverage. These are people whose unpaid labor, valued at more than $1.1 trillion annually per AARP, is already subsidizing a care system the government refuses to fully fund.

What Comes Next

The public comment period on the interim final rule closes July 31, 2026. The rule takes effect the same day. States must implement work requirements by Jan. 1, 2027.

The bill may be called beautiful. What it is doing to families is not.

Step-by-Step: How to Submit a Federal Public Comment

1. Find the rule on Regulations.gov.

• Use the search bar to search the rule ID or title, e.g., “CMS-2454-IFC” or “Medicaid Community Engagement Requirement”
• Filter to “Only show documents open for comment” if needed.

2. Open the rule’s page.

• Click the title of the rule.
• Review:
  • The summary of the rule
  • The comment due date (for this rule: July 31, 2026)
  • Any attachments or the full text in the Federal Register

3. Start your comment.

• Click the blue “COMMENT” button near the top of the page.
• You’ll be prompted to enter your comment in a text box or upload a document (PDF, Word, etc.) with your comment.

3. Identify yourself (unless anonymous).

• If you do not submit anonymously, you must include:
  • Your first and last name if commenting as an individual, or
  • Your organization name and type if commenting on behalf of a group.
• We recommend including your city/state so decision makers can see who is affected.

4. Write an effective comment.

While you can write anything, agencies give more weight to comments that are specific and grounded. A strong structure:

• Introduce yourself: name, location, relevant experience. (For example, “I’m a Medicaid enrollee in Austin, Texas” or “I’m a health policy analyst focusing on coverage and work requirements.”)
• State your position clearly: “I oppose/support the 80‑hour monthly community engagement requirement because…”
• Explain why, using personal or community impacts (e.g., how this affects people with disabilities, caregivers, low‑wage workers, rural residents).
• Be specific: Reference particular sections or requirements if possible (e.g., “the 80‑hour‑per‑month threshold in §X”).
• Suggest concrete changes or alternatives (e.g., exemptions, different hour thresholds, verification procedures)
• If you have data or research, cite it briefly (studies, reports, state experiences with similar policies).
• Close by restating your main ask and thanking the agency.

5. Submit and confirm.

• Follow the on‑screen steps to submit.
• If you provide an email, you should receive a confirmation email that your comment was received.
• You can often view your comment (and others’) on the rule’s page after it’s processed.

*

A note from Ms. editors: We want to hear from you for The Majority, a new campaign collecting stories about how reproductive freedom has enabled readers to build the lives they want and need. Poll after poll shows a majority of Americans support reproductive healthcare access. Yet public debate overlooks the lives shaped by abortion access, contraception, IVF, miscarriage care, maternal healthcare or comprehensive sex education—countless women who chose to pursue an education, have children, not have children, protect their health and chart their own future. Add your voice and complete the sentence: “Access to reproductive choices gave me the freedom to….” Together, these stories will help show not only why reproductive freedom remains a majority value, but also what it makes possible.