“I had to have surgery on my left arm back in April and honestly, if I didn’t have Medicaid, I don’t know how I would have paid for the surgery,” the North Richland Hills hairstylist said by email.
Still undergoing rehab for a spinal cord injury, Cecil is counting on Medicaid to help her heal to the point she can return to work. However, since President Donald Trump this month signed the nearly 1,000-page Budget Reconciliation Act – known as the “One Big Beautiful Bill Act” or BBB for short – that help looks less certain. “My caregivers and I are very worried about the idea of Medicaid being cut,” Cecil said.
In fact, Medicaid cuts are well past the idea stage. The BBB will cut federal funding for the insurance program by $1 trillion over the next 10 years, according to San Francisco health policy research firm KFF. Texas will get about $39 billion less federal support for insuring low-income state residents, KFF estimated.
According to a spokesperson for Texas Health and Human Services, 376,050 residents in Dallas County were enrolled in Medicaid as of November 2024. The number of those who will lose coverage as a result of the BBB depends on how it is implemented at the state and federal levels.
However, KFF estimated more than 300,000 Texas residents could lose health insurance. With around 9% of the state’s population living in Dallas County, that could mean about 27,000 county residents risk becoming uninsured.
It will take time for this to play out. Most cuts won’t hit before 2026 or 2027, and much depends on how the state responds. But eventually it almost certainly will mean some county residents no longer have access to Medicaid. “We’ll see a huge increase in the number of uninsured people in the state,” says Lynn Cowles, the Director of Health and Food Justice at Texas policy and advocacy organization, Every Texan.
Medicaid Cuts Impact
Losing coverage is just one way the BBB cuts will affect Medicaid enrollees. The bill mandates higher barriers to enrolling in and renewing coverage. It also limits state payments to hospitals, health centers, nursing homes and other providers, among other measures.Likewise, the impact will go beyond losing insurance. An analysis published in Annals of Internal Medicine predicted Medicaid enrollees will lose their personal physicians, forgo medications and skip screening procedures such as mammograms. Others will be burdened by medical debts, and some will be refused treatment because of past unpaid medical bills.
Who are these people? In Texas, Medicaid recipients are primarily pregnant women, disabled people, senior citizens, and, especially, children. About 70% of state Medicaid enrollees are under age 19.
It’s worth noting that Texas already has the largest number (about 5 million) and highest percentage (17% or so) of uninsured residents, according to Every Texan’s analysis of 2022 Census data. Cowles warns that adding more uninsured while also reducing payments to providers is likely to rattle the state’s entire healthcare system.
Among other things, people who have private insurance or other means to pay will also see their healthcare bills increase. “When your move over a trillion dollars from healthcare systems around the country, everything will cost more for everybody,” Cowles said.
Medicaid Cuts Good News
Dallas residents won’t have to deal with changes that will affect many Medicaid enrollees around the country. One of the biggest financial impacts of the BBB will come from states instituting work requirements for low-income adults who are enrolled in Medicaid. Those work requirements won’t affect Texans because lawmakers never accepted federal funding that opened up Medicaid enrollment to low-income adults.Also, most changes are specific to adults. It’s unlikely that many kids will be kicked off Medicaid as a direct result of the BBB. That doesn’t mean they won’t experience indirect impacts. For example, parents may be unenrolled for failing to meet heightened paperwork requirements, such as re-enrolling more frequently. If they incorrectly assume that their kids have lost coverage, they may not seek care for enrolled children.
Such scenarios are also likely to be less common in Dallas than in rural counties, where Medicaid pays a larger share of health costs. Many rural hospitals and other providers, faced with declining revenues, will reduce services and some will close. While some Dallas hospitals will be affected, urban providers typically have a lower percentage of Medicaid patients.
BBB Uncertainty
Medicaid cuts also will have little immediate effect. Trump can sign a 940-page bill in a moment, however, notes Simon Haebner, associate professor at Texas A&M University School of Public Health, putting it into effect takes longer. “The Trump admin has to issue a ton of regulations over the next couple of years to implement this,” Haebner said.“And a lot of provisions won’t come into effect for a couple of years,” he added. For example, re-enrollment obstacles are expected to be a prime cause of coverage losses. But many won’t matter much before the end of 2026, after the 12-month enrollment for current recipients ends
Another unknown is how the state will respond. Washington provides 60% of Medicaid funding, but the Texas Legislature and Department of Health and Human Services administer it. After the pandemic, the way Texas handled re-enrolling Medicaid recipients resulted in millions being denied coverage, sometimes for minor paperwork issues.
What will happen this time? A spokesman for the Health and Human Services Commission told the Observer in an email: “HHSC is assessing the impact of the recently passed federal budget. HHSC will work with our federal partners regarding any possible changes to benefits.” The department said no one was available for an interview.
No question the health department has a lot to think about. In addition to Medicaid, the BBB makes major changes to the Affordable Care Act (ACA), including shrinking enrollment periods, that could have more impact.
The Big Beautiful Future
While the intermediate-term future of Dallas County’s Medicaid-enrolled population may look bleak, the longer-term might not be so bad. The BBB is broadly unpopular among voters, especially Democrats, mostly because of Medicaid cuts. Many conservatives dislike it because it is expected to add $3 trillion to the $37 trillion national debt.A June Quinnipiac University poll found 53% of voters opposed the legislation, while only 27% supported it and 20% had no opinion. These results encourage those who favor sustaining or increasing Medicaid funding to foresee a backlash in the 2026 midterm elections that could give their views more clout in Washington.
From a state perspective, Haebner speculated that, because the bill’s changes to Medicaid and the ACA have Trump’s explicit endorsement, Medicaid may look more palatable to our elected officials. Ultimately, coverage might actually improve.
“In a place like Texas, that is very conservative and was very anti-Obama and anti-ACA, the Trump administration taking ownership of ACA and molding it in a more conservative way, including work requirements, might open the door for the state to expand their Medicaid program in line with what the ACA originally offered,” Haebner said.
Rather than wait for that, Dallasites currently enrolled in Medicaid can take steps on their own to maintain coverage. Medicaid enrollees can start by paying close attention to their status and paperwork, Cowles said. “Make sure your address is up to date,” she noted. “Make sure you open mail from the healthcare commission and respond appropriately.” If questions arise, reach out to Healthcare Navigators, people and organizations trained to help Medicaid applicants determine eligibility and enroll.
That advice is echoed by Brandy Taylor-Dédé, Dallas-based state director for the Children’s Defense Fund. “Continue to stay connected with [healthcare] navigators,” Taylor-Dédé said. “Because of cuts to federal funding to Navigator programs, there may be fewer of those, but they are the outreach specialists who are closely connected to families and are aware of the changes.” United Way of Metropolitan Dallas oversees the network of certified healthcare navigators for North Texas.
Medicaid recipients also need to maintain communication with hospitals, community care centers and other providers, Taylor-Dédé said. In addition, people needing care may be able to tap providers that offer low- or no-cost care based on income, including clinics run by UT Southwestern Medical Center students and Catholic Charities Dallas.
At bottom, the BBB can be seen as a massive shift of healthcare funding for low-income people away from federal taxpayers, where it’s primarily resided for the last 60 years. “The One Big Beautiful Bill Act will transfer responsibility for their healthcare onto other people,” Cowles said. Texas may step up instead. But if not, Cowles continued, “Their neighbors will have to take care of them.”
That is where Jade Cecil turned in 2024 when she set up a GoFundMe to raise $50,000 for her care. A year later, the fund had accumulated 21 donations totaling $1,687.
