The hotly contested One Big Beautiful Bill Act was passed by the U.S. House of Representatives for a second and final time with a vote of 218–214. It will now move to President Donald Trump’s desk for signing.

The legislation will make deep cuts to Medicaid and changes to the Affordable Care Act (ACA) and health insurance marketplaces, which could result in nearly 17 million losing their health insurance coverage over the next nine years.

The Congressional Budget Office (CBO) estimates that with the bill’s passage, by the year 2034, the number of uninsured Americans will increase by 11.8 million. This estimate includes 1.4 million undocumented individuals who would no longer be covered in state-only Medicaid-funded programs.

The CBO previously noted that an additional 5.1 million could become uninsured on top of this estimate as a result of other policy changes in the bill to the ACA and the expiration of enhanced premium tax credits. 

As the largest payer in the nation for both substance use disorder (SUD) treatment and mental health services, Medicaid cuts threaten access to necessary treatments. It could also hurt providers who rely heavily on Medicaid reimbursement for providing these services, forcing them to cut offerings or swallow the burden of providing uncompensated care.

“In very real terms, this legislation will result in irreparable gaps in access to care for our country’s most vulnerable, many of whom have mental health and substance use disorders, and they will suffer as a result,” Dr. Theresa Miskimen Rivera, president of the American Psychiatric Association, said in a statement.

Republicans counter that the bill strengthens Medicaid and Medicare by cracking down on waste, fraud and abuse – ultimately ensuring “these programs are benefiting the American citizens they were designed to benefit.”

The bill originally passed the House on May 22 and was sent to the Senate for review. After a weekend vote-a-rama that ended with Vice President JD Vance making the tie-breaking decision in its favor, the amended bill was sent back for the House’s review on July 1.

Following procedural votes on July 2, the House advanced the bill for a final debate on the floor. After deliberating late into the night, debate opened to the floor on July 3, during which House Minority Leader Hakeem Jeffries (D-N.Y.) spoke for 8 hours and 44 minutes, delaying the bill’s passage and urging Republican holdouts to join Democrats in rejecting the legislation.

The speech surpassed the record for the longest House floor speech ever given, which was previously 8 hours and 32 minutes in 2021 held by former House Minority Leader Kevin McCarthy (R-Calif.).

“I rise today in strong opposition to Donald Trump’s disgusting abomination …that guts Medicaid, rips food from the mouths of children, seniors and veterans and rewards billionaires with massive tax breaks,” Jeffries said during his marathon speech.

He called the matter “a question for so many individuals of life and death” and referred to the bill as a “reckless” and “immoral document” with a budget that “tears people down.”

Jeffries reiterated that rural health care and hospitals, including behavioral health services, will be hurt and in some cases may shut down entirely.

Sixty-one industry groups, including the National Alliance on Mental Illness, American Psychiatric Association, National Council for Mental Wellbeing, American Foundation for Suicide Prevention, and others, signed onto a joint letter addressed to House Speaker Mike Johnson (R-La.) and Jeffries stressing the negative ramifications the legislation would have.

“We continue to be deeply concerned that cutting Medicaid funding or benefits, as well as imposing burdensome eligibility and work requirements, would disproportionately harm people with mental health conditions and substance use disorders,” the letter states. “The need for mental health and SUD services would not go away. Many people would be forced to forgo community-based and routine mental health and SUD care, such as therapy, prescription mental health medications, and medications for opioid use disorder.”

The joint letter also underscores the disproportionate impact Medicaid cuts will have on rural behavioral health, which other industry experts have also expressed.

“There’s a gap in care that is consistently filled by Medicaid,” Dr. Jon Ulven, behavioral health psychologist and chair of adult psychology at Sanford Health, said during a July 2 American Hospital Association podcast. “Essentially, these folks would possibly be in a situation where they would have no care, no access to care … I hope that what this has done is just increase an awareness of the truly wide-reaching effects that a change in Medicaid is going to have for the way that we deliver health. And I would say especially in rural health care.”

Sanford Health is the largest rural health system in the U.S.

The legislation also calls for new work requirements beginning in 2026 for Medicaid recipients, enforcing that for eligibility, adults must work, volunteer or study at least 80 hours per month to qualify for benefits. There are exemptions for caregivers of dependents and others. The Senate’s amendment to the bill requires parents of children who are older than 14 to work.

Under this new framework, Medicaid recipients will be required to prove eligibility twice a year instead of annually, as has previously been the case.

These new requirements will only add to an already burdened system and “create a perfect storm for safety-net mental health and substance use treatment organizations,” according to the National Council for Mental Wellbeing.

“The results will include longer waiting times, fewer services available and more people diverted to emergency rooms and local jails,” the National Council for Mental Wellbeing wrote in a statement.

Many aspects of the bill will not go into effect until 2026. As part of President Trump’s overall budget plan, he previously proposed cutting over $28.6 billion in health care and mental health-related spending under its discretionary budget for FY 2026.