In July 2025, Republicans passed Trump's budget bill — the one they called the "One Big Beautiful Bill." It cut Medicaid by close to $1 trillion over 10 years. The Congressional Budget Office says the law will lead to a 10 million increase in the number of uninsured Americans.

The biggest single cut, work requirements, takes $326 billion out of Medicaid. It doesn't start until January 1, 2027.

The midterms are November 3, 2026.

That order is not an accident.

The timer was set deliberately

Congressional Republicans wrote the Medicaid cuts into the law in a way that kicks in right after Election Day. The work requirements — which require adults to document 80 hours a month of work, volunteering, or school or lose their coverage — take effect January 1, 2027. The deeper funding cuts come later still: the squeeze on state provider taxes starts October 1, 2027, and the cap on state-directed payments January 1, 2028.

As political scientist Norman Ornstein put it in the New Republic, Republicans "made sure to postpone them until 2027, conveniently after the midterm elections."

We already know why. Politicians who voted to strip health coverage from millions of their own constituents do not want those constituents thinking about that vote on Election Day. So they designed the bill to make sure the damage lands after the ballots are counted.

Republican members have gone to great lengths to deny this is even happening. Some introduced bills to fix rural hospitals months after voting for the law that put those hospitals at risk. But the mechanism is in the text of the law. The timer is running.

What actually happens in January

The work requirements alone apply to adults who get coverage through the Affordable Care Act's Medicaid expansion, unless they qualify for an exemption. That's 41 states, counting Washington, D.C., that chose to cover nearly all low-income adults.

Starting in 2027, states have to check those adults' work status when they apply and at every renewal — every six months, or more often if the state chooses — and confirm they met the 80-hour threshold. States have to build systems to check. People who miss a month — because they were sick, because their employer's hours changed, because they couldn't get documentation in time — lose coverage. Ninety-two percent of working-age adults on Medicaid already work, care for someone, go to school, or can't work because of illness or disability.

The rule isn't designed to find people who could work but don't. It's designed to create paperwork barriers that cause people to lose coverage they earned. That's what happened in Arkansas in 2018, the first state to try work requirements before a federal court struck them down. 18,000 people lost coverage.

Who gets hurt first

Medicaid is not just insurance for unemployed adults. It is the backbone of the American healthcare system.

More than 6 in 10 nursing home residents have Medicaid as their primary payer. Nursing homes get paid Medicaid rates. When those rates get cut and enrollment drops, facilities close. The residents who remain have nowhere to go. 1.2 million people lived in nursing facilities as of July 2024. There is no private market that covers their care.

Rural hospitals were already on the edge before the law passed. We've written about this at length — hospitals in rural districts that depend on Medicaid reimbursements for a substantial share of their revenue. When those reimbursements shrink and the uninsured rate climbs, those hospitals don't restructure. They close. Emergency rooms go dark. People drive an hour to a hospital instead of ten minutes.

2.6 million Americans have already lost health insurance since the ACA subsidies expired — before the Medicaid cuts even begin. The January cliff makes that number much larger.

The rest of the healthcare system is already under stress

The budget bill's Medicaid cuts don't arrive into a stable system. They arrive into one already being disrupted from multiple directions.

RFK Jr. has spent the past year pushing anti-vaccine conspiracy theories and attacking flu and COVID vaccines, alongside what Ornstein calls "the evisceration of food safety programs". Measles is back. These are not coincidental side effects. They are the results of deliberate policy choices by the man Trump put in charge of the nation's health.

Meanwhile, the deportation campaign is coming for the people who staff those facilities. More than 100,000 Haitians have worked in health care — many in nursing homes and home health — and they are losing Temporary Protected Status. Byron Donalds of Florida suggested those workers could be replaced with high school interns and adult retraining programs. They cannot.

The healthcare system running into the January cuts is already short-staffed, short-funded, and dealing with disease outbreaks.

The political math, openly stated

What Republicans have built is a law that:

• Leaves 10 million more people uninsured, by CBO's count
• Forces states to build massive new bureaucracies to check work requirements
• Cuts nursing home funding in ways that will close facilities
• Defunds rural hospitals in districts that voted Republican
• Starts its biggest cut 59 days after the midterm elections

The timing isn't a design flaw. It's the design. They needed the votes in November 2026. They didn't need the consequences until 2027.

The members who wrote and passed this law have names. 198 of them have report cards on this site, and every one is running in November. Their names are below. Their constituents are among the millions who will lose coverage. And for the next 30 days — until Election Day — those constituents are being asked to vote without yet experiencing what they voted for.

Every one of them voted yes

The Senate passed the bill on July 1, 2025, 50 to 50, with Vice President JD Vance breaking the tie. Republicans voted 50 to 3 for it. The House passed it two days later, on July 3, 218 to 214. Republicans voted 218 to 2 for it, and not one Democrat voted yes.

Here is every Republican on this site who voted yes: 13 senators and 185 House members. Six more House members who voted yes also have report cards here but are no longer running: Chuck Edwards, Cory Mills, Andy Ogles, John Rose, David Schweikert and Ralph Norman.

Alabama — Sen. Tommy Tuberville, Robert Aderholt, Barry Moore, Gary Palmer, Mike Rogers, Dale Strong

Alaska — Sen. Dan Sullivan, Nick Begich

Arizona — Andy Biggs, Juan Ciscomani, Eli Crane, Paul Gosar, Abraham Hamadeh

Arkansas — Sen. Tom Cotton, Rick Crawford, French Hill, Bruce Westerman, Steve Womack

California — Ken Calvert, Vince Fong, Kevin Kiley, Young Kim, Tom McClintock, Jay Obernolte, David Valadao

Colorado — Lauren Boebert, Jeff Crank, Gabe Evans, Jeff Hurd

Florida — Sen. Ashley Moody, Aaron Bean, Gus Bilirakis, Kat Cammack, Mario Diaz-Balart, Byron Donalds, Randy Fine, Scott Franklin, Carlos Gimenez, Mike Haridopolos, Laurel Lee, Anna Paulina Luna, Brian Mast, Jimmy Patronis, John Rutherford, Maria Elvira Salazar, Greg Steube

Georgia — Rick Allen, Andrew Clyde, Mike Collins, Brian Jack, Rich McCormick, Austin Scott

Idaho — Sen. Jim Risch, Russ Fulcher, Mike Simpson

Illinois — Mike Bost, Darin LaHood, Mary Miller

Indiana — Jim Baird, Erin Houchin, Mark Messmer, Jefferson Shreve, Victoria Spartz, Marlin Stutzman, Rudy Yakym

Iowa — Ashley Hinson, Mariannette Miller-Meeks, Zach Nunn

Kansas — Sen. Roger Marshall, Ron Estes, Tracey Mann, Derek Schmidt

Kentucky — Andy Barr, James Comer, Brett Guthrie, Hal Rogers

Louisiana — Clay Higgins, Mike Johnson, Julia Letlow, Steve Scalise

Maryland — Andy Harris

Michigan — Tom Barrett, Jack Bergman, Bill Huizenga, John James, Lisa McClain, John Moolenaar, Tim Walberg

Minnesota — Tom Emmer, Brad Finstad, Michelle Fischbach, Pete Stauber

Mississippi — Sen. Cindy Hyde-Smith, Mike Ezell, Michael Guest, Trent Kelly

Missouri — Mark Alford, Eric Burlison, Bob Onder, Jason Smith, Ann Wagner

Montana — Troy Downing

Nebraska — Sen. Pete Ricketts, Mike Flood, Adrian Smith

New Jersey — Jeff Van Drew, Tom Kean Jr., Chris Smith

New York — Andrew Garbarino, Nick LaLota, Nick Langworthy, Mike Lawler, Nicole Malliotakis, Claudia Tenney

North Carolina — Virginia Foxx, Pat Harrigan, Mark Harris, Richard Hudson, Brad Knott, Addison McDowell, Tim Moore, Greg Murphy, David Rouzer

North Dakota — Julie Fedorchak

Ohio — Sen. Jon Husted, Troy Balderson, Mike Carey, Warren Davidson, Jim Jordan, David Joyce, Bob Latta, Max Miller, Michael Rulli, David Taylor, Mike Turner

Oklahoma — Stephanie Bice, Josh Brecheen, Tom Cole, Kevin Hern, Frank Lucas

Oregon — Cliff Bentz

Pennsylvania — Rob Bresnahan, John Joyce, Mike Kelly, Ryan Mackenzie, Dan Meuser, Scott Perry, Guy Reschenthaler, Lloyd Smucker, Glenn Thompson

South Carolina — Sheri Biggs, Russell Fry, William Timmons, Joe Wilson

South Dakota — Sen. Mike Rounds

Tennessee — Sen. Bill Hagerty, Sen. Marsha Blackburn, Tim Burchett, Scott DesJarlais, Chuck Fleischmann, Diana Harshbarger, David Kustoff

Texas — Brian Babin, John Carter, Michael Cloud, Monica De La Cruz, Beth Van Duyne, Jake Ellzey, Pat Fallon, Brandon Gill, Craig Goldman, Lance Gooden, Ronny Jackson, Nathaniel Moran, August Pfluger, Keith Self, Pete Sessions, Randy Weber, Roger Williams

Utah — Mike Kennedy, Celeste Maloy, Blake Moore

Virginia — Ben Cline, Morgan Griffith, Jen Kiggans, John McGuire, Rob Wittman

Washington — Michael Baumgartner

West Virginia — Sen. Shelley Moore Capito, Carol Miller, Riley Moore

Wisconsin — Scott Fitzgerald, Glenn Grothman, Derrick Van Orden, Bryan Steil, Tom Tiffany, Tony Wied

Wyoming — Harriet Hageman

What the record shows

Republicans passed a law cutting Medicaid by close to $1 trillion over 10 years. CBO says it will leave 10 million more people uninsured. More than 6 in 10 nursing home residents rely on Medicaid. Rural hospitals already operating on thin margins face closure when Medicaid rolls and reimbursements fall. The work requirements take effect on January 1, 2027 — 59 days after the midterms — and the deeper funding cuts follow in 2027 and 2028. The people who voted for this law are asking for your vote before you feel what they did.

Sources

• Senate Roll Call 372: H.R. 1, the One Big Beautiful Bill Act, July 1, 2025 (passed 51–50, Vice President breaking a 50–50 tie)
• House Roll Call 190: H.R. 1, motion to concur in the Senate amendment, July 3, 2025 (passed 218–214)
• The Republicans Are Going to Kill People—but Not Until After They Vote — The New Republic, August 16, 2026
• KFF: A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law
• KFF: Health Provisions in the 2025 Federal Budget Reconciliation Law