I have spent my career working on the front lines of medicine, in the place where every system failure eventually lands: the emergency department. I’ve seen the consequences of delayed care, the quiet tragedies of untreated chronic disease, the frantic resuscitations that could have been prevented if the patient had simply been able to see a doctor sooner.
That’s why the passage of HR 1 – the so-called “One Big Beautiful Bill Act” – isn’t just bad policy. It’s a blueprint for dismantling the safety net that keeps millions alive.
Let’s be clear: despite its branding, there is nothing “beautiful” about this bill. It will strip insurance from millions, bleed providers dry, and put an impossible strain on the already-crumbling infrastructure of our health care system. And when the dust settles, it will be our exam rooms, our hospital wards, and our ED bays that become the last, overcrowded refuge for the people it abandons. Below is a summary of the most significant and damaging changes.
Coverage Reductions
- Medi-Cal: An estimated 2.5 million enrollees are projected to lose coverage.
- Covered California: Up to 2.6 million participants may be priced out of coverage as Affordable Care Act premium tax credits expire, with premiums projected to increase by up to 66% for nearly 2 million people.
Increased Out-of-Pocket Costs
- Beginning in 2028, new $35 copays will be imposed on Medicaid expansion enrollees for each service, which may act as a barrier to care for low-income patients.
Provider Payment Reductions
- The bill includes an estimated $128 billion in cuts to California’s health care system over 10 years through provider tax reductions and caps on state-directed payments.
- These cuts are expected to lower hospital and physician payment rates, leading to service reductions or closures.
Impact on Access to Care
- California hospitals and physicians are projected to face $9.5 billion in additional uncompensated care costs over the next decade as more patients lose insurance.
- Provider shortages may worsen, particularly in rural areas where hospitals and clinics already operate with limited resources.
Economic Impact
- The legislation is projected to result in the loss of 217,000 health care jobs in California.
- The state’s economic output could decline by $37 billion, with an estimated $1.7 billion reduction in state and local tax revenue.
Work and Reporting Requirements for Medicaid
- Many adult Medicaid enrollees will be required to complete 80 hours per month of work, school, or community service, with monthly reporting requirements.
- It is estimated that over 4.8 million otherwise eligible adults nationwide could lose coverage due to administrative or documentation challenges.
Planned Parenthood Funding
- A one-year Medicaid defunding of Planned Parenthood will remove approximately $305 million in California, affecting more than 80% of the state’s 1.2 million annual patient visits to Planned Parenthood clinics.
Medical Education Funding Changes
- Federal borrowing for medical school will be capped at $200,000, below the total cost for many programs. This change may limit access to medical education, particularly for students from lower-income backgrounds.
Medicare Payment Adjustments
- The bill provides a temporary 2.5% Medicare physician payment increase in 2026.
- Beginning in the same year, an additional 2% Medicare sequestration cut will take effect.
- The bill does not address long-standing structural underfunding of physician services.
I’m not writing this because I enjoy politics. I’m writing this because I know exactly what’s coming, and so do you. More patients forced into already-packed emergency departments because there is nowhere else to go. We’ll see more hallway beds, more eight-hour waits, more “sorry, there’s nothing we can do tonight” conversations that haunt you long after your shift ends. We will be asked to do more with less – fewer reimbursements, fewer resources, fewer colleagues to share the load. The moral distress that so many of us already feel will deepen, especially because we will know that much of this suffering was preventable.
Colleagues, we have to fight this. Not with a resigned sigh, not with a couple of angry tweets, but with sustained, coordinated advocacy. SSVMS and CMA are already mobilizing to reverse this disaster and we need everyone in on this fight. We need to be in legislators’ offices, in their inboxes, and in the public square. We need to tell the stories that make this more than numbers on a spreadsheet. We need to make it impossible for anyone to ignore the human cost of this law.
And we need to look out for each other. Burnout will spike. Frustration will rise. But our patients need us clear-eyed and loud-voiced. The “Big Beautiful Bill” is now the law of the land, but laws can be challenged, amended, repealed. History is full of policy reversals driven by sustained outrage, creative coalitions, and relentless advocacy.
Because the truth is simple: when health care is gutted, people die. And as physicians, we know better than anyone what those deaths look like.
I will not quietly watch this happen. Neither should you.
