The Biggest Healthcare Cuts in US History Won’t Damage Republicans as Much as You Think

Although Republicans frame their One Big Beautiful Bill as an extension of Trump’s 2017 tax cuts, the bill also contains massive cuts to federal healthcare coverage. The nonpartisan Congressional Budget Office estimates that the bill will reduce federal spending on the Affordable Care Act and Medicaid by $1 trillion USD and will cause 12 million more Americans to become uninsured by 2034. Enrolment in the Affordable Care Act marketplace, a platform where individuals purchase healthcare plans, will decrease by between 47 and 57 per cent. These estimates mark a stunning reversal from years of expanding federal healthcare coverage since the passage of the Affordable Care Act in 2010. In 2023, 25 million Americans were uninsured, marking the lowest level ever recorded. Historically, as federal funding expanded, the idea of public healthcare became more popular among voters, who increasingly said that the federal government should be responsible for providing at least some healthcare to Americans. 

Due to these cuts to public healthcare, the One Big Beautiful Bill is unpopular. A Quinnipiac poll found that only 27 per cent of respondents outright supported the legislation. A different poll had similar results among Republicans: just 61 per cent of Republicans have a favourable view of the bill, substantially lower than Republicans’ views on Trump’s other legislative priorities. As a result of the popularity of public healthcare, these cuts are politically risky for Republicans because a large portion of their increasingly working-class electorate relies on Medicaid for healthcare coverage. These cuts, then, risk alienating working-class voters who have migrated from the Democratic Party in support of Donald Trump.

Conveniently for Republicans, these controversial cuts to public healthcare funding take effect after the 2026 midterm elections. Medicaid work requirements, which require enrolees to work or volunteer for at least 80 hours a month, take effect at the end of 2026. A pre-enrolment Affordable Care Act eligibility verification takes effect at the end of 2027. This verification will reduce enrolment by requiring enrolees to complete onerous paperwork, creating additional bureaucratic steps that eligible Americans may struggle to navigate. From October 2028 onwards, Medicaid enrolees will be required to pay out-of-pocket for certain benefits, including prescription drugs and physical therapy, potentially incurring an additional cost of up to $35 USD per service.    

Despite the controversy over healthcare cuts in the One Big Beautiful Bill, Republicans face another healthcare dilemma—whether to extend the Affordable Care Act tax credits that Democrats passed in 2021. These tax credits, extended through the Inflation Reduction Act in 2022, lowered monthly premiums and have doubled enrolment in Affordable Care Act policies since 2021. They are set to expire on January 1 2026 if Republicans do not extend them, which seems increasingly likely. If they expire, the average premium will increase by $1,500 USD a month for couples earning $85,000 USD. This will cause 4.2 million people to lose their insurance by 2034.   

The Affordable Care Act tax credits are popular, even among those who voted for Donald Trump: 63 per cent of Republicans say that Congress should extend the Affordable Care Act tax credits. When self-identifying ‘MAGA Republicans’ are polled, support remains at 56 per cent. From these polls, it is clear that both the healthcare cuts in the One Big Beautiful Bill and the expiry of the Affordable Care Act tax credits are deeply unpopular policy decisions among broad swaths of the electorate. However, one key difference separates them: the tax credits expire at the end of 2025, whereas the bulk of the recent healthcare cuts take effect several years from now. This means that the expiring tax credits, not the healthcare cuts, present a more imminent political threat to Republicans because voters will experience their effects before the 2026 midterms. On the other hand, voters won’t notice the bulk of the $1 trillion USD in healthcare spending cuts until after 2026. Since Republicans cleverly made their extension of Trump’s 2017 tax cuts take effect immediately, they will be able to claim that they created tax relief for the working class without massively cutting public healthcare in the run-up to the 2026 midterms. However, Republicans do not enjoy the same cushion when it comes to the expiring tax credits. If the tax credits are not extended by September, voters will notice the cost increase when they enrol for their healthcare plans in November. 

In the 2018 midterms, failed Republican attempts to repeal the Affordable Care Act allowed Democrats to gain 40 seats in the House of Representatives—their largest gain since 1974. In the 2026 midterms, Democrats will be able to argue that the One Big Beautiful Bill enacts the largest federal healthcare cuts in history and that Republicans allowed the Affordable Care Act tax credits to expire. In 2026, Republicans might get away with their One Big Beautiful Bill by cleverly extending the 2017 tax cuts years before cuts to healthcare services take effect. However, letting the tax credits expire will prove more damaging than both the One Big Beautiful Bill and attempts to repeal the Affordable Care Act because voters will feel the effects before the midterm elections.

If 2018 taught us anything, it’s that trying to take away public healthcare is deeply unpopular. The difference between now and then is that Republicans finally succeeded in stripping Americans of these services. This means that, like the 2018 midterms, Republicans should expect substantial losses in 2026 that could threaten their congressional majorities. However, Republicans should expect the bulk of these electoral losses to come from anger at the expiry of the Affordable Care Act tax credits, not the cuts to public healthcare. More importantly, though, Republicans should worry about losing their diverse working-class coalition, many of whom supported Donald Trump’s 2024 presidential campaign on the promise that their access to Medicaid would be protected.

Edited by Madeleine Glover 

Featured image: President Donald Trump signs the One Big Beautiful Bill Act on the South Lawn of the White House,” by Daniel Torok is licensed under United States Government Work.