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U.S. President Donald Trump takes the stage during a reception for Republican members of the House of Representatives in the East Room of the White House on July 22, 2025 in Washington, DC. Trump thanked GOP lawmakers for passing the One Big Beautiful Bill Act.
Getty Images, Chip Somodevilla
Just the Facts: Impact of the Big Beautiful Bill on Health Care
Sep 15, 2025
The Fulcrum strives to approach news stories with an open mind and skepticism, striving to present our readers with a broad spectrum of viewpoints through diligent research and critical thinking. As best we can, we remove personal bias from our reporting and seek a variety of perspectives in both our news gathering and selection of opinion pieces. However, before our readers can analyze varying viewpoints, they must have the facts.
What are the new Medicaid work requirements, and are they more lenient or more restrictive than what previously existed?
The Big Beautiful Bill imposes federal work requirements for Medicaid for the first time. Starting January 1, 2027, most able-bodied adults must work, volunteer, or attend school for at least 80 hours per month to maintain coverage. Exemptions apply to seniors over 65, pregnant women, and parents of children under 14—but caregivers of older dependents or those with disabilities may not qualify for exemptions, making the policy more restrictive than prior state-level waivers.
Previously, work requirements were only allowed through state waivers and were often blocked or reversed by courts or federal agencies. The new law nationalizes and tightens these rules, adding complex reporting requirements and frequent verification deadlines. Analysts warn this will likely lead to coverage losses, especially among low-income workers, caregivers, and those facing logistical barriers like unreliable transportation or internet access.
Does Medicaid still cover gender-affirming care? No. The bill bans Medicaid funding for gender transition therapies, including hormone treatments and surgeries.
How does the bill change retroactive Medicaid coverage? The Big Beautiful Bill reduces the retroactive Medicaid coverage window from 90 days to 30 days, significantly limiting the timeframe in which past medical expenses can be reimbursed.
What is retroactive Medicaid coverage? Retroactive coverage allows Medicaid to pay for medical bills incurred up to three months before a person formally applies, as long as they would have qualified during that time. For example, if someone is hospitalized in January but doesn’t apply for Medicaid until March, retroactive eligibility could cover those January and February bills—assuming they met income and asset requirements then.
This provision has historically served as a safety net for low-income individuals facing sudden illness, injury, or hospitalization before they could complete the complex Medicaid application process. By shortening the window to just 30 days, the bill reduces flexibility for patients and providers, and may leave more people with unpaid medical debt during critical health events.
Can states still impose fees or assessments on healthcare providers—like hospitals, nursing homes, or clinics—that help states fund their share of Medicaid costs, and if not, how will this impact costs for Americans?
Under the Big Beautiful Bill, states are prohibited from establishing new provider taxes or increasing existing ones. These taxes have historically been levied on hospitals, nursing homes, and other providers, and they have been a key mechanism for states to generate revenue that qualifies for federal Medicaid matching funds. By restricting this tool, the bill limits states’ ability to finance their share of Medicaid, especially during economic downturns or budget shortfalls.
What changes affect the Children’s Health Insurance Program (CHIP), and how will this impact child care costs for Americans?
The Big Beautiful Bill imposes a series of constraints on CHIP, including a reduction in retroactive coverage from 90 days to 30 days, and a 10-year moratorium on new eligibility and enrollment regulations. It also freezes modernization efforts that would have expanded access and streamlined enrollment for children in low-income families.
Additionally, the bill penalizes expansion states that cover lawfully residing immigrant children under CHIP, potentially forcing up to 17 states to drop coverage or absorb higher costs. These changes could lead to coverage losses, increased administrative burdens, and reduced flexibility for states to respond to child health needs.
While CHIP itself doesn’t directly subsidize child care, its erosion can have indirect financial consequences:
- Families losing CHIP coverage may face higher out-of-pocket medical expenses, reducing disposable income available for child care.
- Children without coverage may experience delayed care or untreated conditions, increasing the need for specialized or emergency child care.
- States may redirect funds from child care subsidies to offset CHIP-related shortfalls, especially in expansion states facing penalties.
In parallel, the Big Beautiful Bill expands dependent care tax credits, raising the Child and Dependent Care Tax Credit from 35% to 50% of qualified expenses, and increasing Dependent Care Assistance Plan limits from $5,000 to $7,500. These provisions may offer partial relief to families—but only for those who qualify and can navigate the new tax structures.
How does the bill impact ACA Marketplace subsidies and enrollment?
Special enrollment based on projected income is eliminated. Annual income verification is now required, and repayment caps for excess tax credits are removed.
Can undocumented immigrants access ACA subsidies under the new law?
No. The bill bars undocumented and temporarily documented immigrants from receiving Affordable Care Act tax credits.
What reforms target Pharmacy Benefit Managers (PBMs)?
The bill introduces pricing transparency and regulatory oversight to potentially reduce PBM influence and lower prescription drug costs.
How is Medicare fraud detection enhanced?
$25 million is allocated to the Department of Health and Human Services to deploy artificial intelligence for identifying and recovering improper Medicare payments.
Will Medicare funding be affected by deficit triggers?
Yes. Automatic sequestration provisions could reduce Medicare reimbursements if federal deficit thresholds are exceeded.
What support is provided for rural hospitals?
Closed rural hospitals may reopen under the Rural Emergency Hospital (REH) designation, expanding access in underserved communities.
What is the projected impact on health insurance coverage?
According to the Congressional Budget Office, up to 13.7 million Americans could lose health coverage by 2034, including 7.8 million from Medicaid alone.
How much federal healthcare spending is cut?
The bill reduces direct healthcare reimbursements by an estimated $910 billion over the next decade.
David Nevins is publisher of The Fulcrum and co-founder and board chairman of the Bridge Alliance Education Fund.
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Attendees hold candles during a candlelight vigil and prayer event for Turning Point USA Founder Charlie Kirk on September 10, 2025 in Seattle, Washington.
(Photo by David Ryder/Getty Images)
America Needs a Concerted Campaign Against Political Violence
Sep 14, 2025
Condemning the abhorrent assassination of Christian nationalist leader Charlie Kirk is fundamental and insufficient.
The only way to pull back from the heightening potentials for political violence in America is to mount a concerted, multifaceted campaign against it – and the hyperpolarized intolerance that is producing it. That will require leadership of politicians, religious and civic leaders, as well as influencers, and entertainment and sports celebrities.
I’ve seen the horrible effects of political violence in Africa, Asia, the Balkans, and Latin America as I worked with democracy activists in multiple countries, and it is clear that if the Americans do not act now, violence on a greater scale will come.
Utah’s Republican Governor Spencer Cox, speaking at a press conference immediately after Kirk’s murder, put it dramatically: “We just need every single person in this country to think about where we are and where we want to be, to ask ourselves: Is this it? Is this what 250 years have wrought on us? I pray that that’s not the case.”
No matter what one thinks of the anti-immigrant, anti-choice, anti-gay, and related doctrine aimed at “saving Western civilization” that Charile Kirk professed, his murder is a tragedy. No matter how strongly one believes in that doctrine or in its antithesis, there is no justification for his or any other political killing. That is not just a matter of individual soul-searching; it is a matter of the political culture that we create and demands we make as a society.
Governor Cox referenced the political killings of a Minnesota Democratic state legislator and her husband and the violent attempt against Pennsylvania’s Democratic Governor earlier this year, as well as the attempted assassination of President Trump at a 2024 campaign rally. Sadly, they are not the only such events over the last few years that must be seen along with innumerable threats against individuals and political gatherings. Plus, the deadly January 6, 2021, assault on the U.S. Capitol casts an indelible shadow over our political landscape.
We must all ask what political violence could be next and what must be done to prevent it.
Unfortunately, unlike past presidents who called for national unity in the face of political violence, President Trump and key members of his administration, immediately following Charlie Kirk’s murder, fostered further division, blaming the left for the killing and threatening a political crackdown. Social media posts calling for arresting elected Democrats and banning the party and – even more dramatically declaring “war” – feed off such crackdown threats even as disgusting celebratory posts about Kirk’s murder feed anger. Antidotes to intolerance and hatred are urgently needed instead.
Governor Cox, at a press conference on September 12, calling for sanity over violence, offered a stark choice:
"We can return violence with fire and violence. We can return hate with hate. And that's the problem with political violence, is it metastasizes, because we can always point the finger at the other side, and at some point we have to find an off-ramp, or it's going to get much, much worse. These are choices that we can make."
Thus far, those who exert outsized cultural influence in the U.S. have remained silent or spoken once and then moved on. If we are to ramp down the heightened potentials for large-scale political violence, let alone find an off-ramp, Americans have to raise our voices now and call on political, religious, and cultural leaders to do so.
Even more, they and we need to sustain a chorus that pulls away from violence – otherwise, its attraction may well become much stronger. So, sing out no matter where you stand politically, and demand that leaders raise their voices from the mountaintops.
Pat Merloe provides strategic advice to groups focused on democracy and trustworthy elections in the U.S. and internationally. He is a long-time resident of Washington, D.C.
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U.S.A. flag
Photo by Lucas Sankey on Unsplash
The Crux of the Schism: What defines being American?
Sep 14, 2025
Undeniably, the U.S. body politic is in crisis today and has likely been unraveling for more than a decade. The rancorous polarization best exemplified by the demonization of MAGA on one side, and the elite establishment on the other, has become a daily preoccupation in many circles. True, there is undoubtedly a large group of Americans in a broadly defined center whose voices get drowned out by the extremes who scream the loudest. Yet despite this caveat, we are arguably witnessing the most ominous threat we’ve faced since the Civil War tore us asunder more than 150 years ago.
Much scrutiny focuses on the political, economic, and social aspects of the schism, all of which are important and in play. However, I would venture to guess that at its core, the disunion lies in the clashing concepts of what being an American signifies, and further, how these concepts have collided over the course of three centuries. While often not debated forthrightly, the battle can be distilled down to two conflicting views on the fundamental question of what constitutes being an American.
On the one hand, what one might call the Progressive View maintains that being American is about the specific ideals anchored in our nation’s founding creed: all men are created equal and hold an inalienable right to self-determination. Underlying it are the universal ethos and values of human dignity, which were reincarnated in the modern era during the 18th-century Enlightenment. In the following century, the great President who preserved the union stipulated our remaining imperative as a demand to live up to those ideals, and effectively rebirthed the nation. By doing so, he charted our agenda during the last century, when millions of Americans died in the noble cause of its defense.
While our country has been far from attaining those ideals, the progressive philosophy embraces the notion that our union is a work in progress. At the same time, imperfect and at times wholly derelict, each generation gets to build on its own definition of Americanism and strives to harness it to the best of its ability.
Juxtaposed to this view is what I might call the New Right View (ironically labeled since it is hardly new by any stretch of the imagination). This perspective focuses on historical continuity, arguing that Americanism is rooted in the values and traditions of the original Anglo-Saxon Protestant settlers. It highlights the importance of ancestral lineage and stability with the mores of past generations.
As a proponent of the former view, I admit to often having a visceral rejection of this latter one. In my quest to bridge the American Schism, however, I have come to understand that this competing view is based on a distinctive set of tenets that are quite valid in their own right. Founded more on continuity than on specific ideals, this interpretation recognizes that at the most fundamental level, the dominant characteristic of our species is one of loyalty, first to family and then to tribe, and ultimately to nations. As perhaps best described in Yoram Hazony’s latest work, The Virtue of Nationalism, allegiance and belonging are best regarded as concentric circles within which humans are born, mature, and ultimately become comfortable living and working. Our modern (and often quite sanctimonious) defense of self-determination cannot ignore the reality that our founders did represent a set of tribes that established a nation with a specific idea of who was to be included.
In summary, our present schism is best represented as a war between those who have embraced the notion of pluralism as a defining feature of our republic and those who reject it. What compounds the fuel in this fire is the dynamic interplay over time between these omnipresent yet incompatible views. Over the last few decades, as the “establishment” has gradually adopted this progressive view as the agreed-upon state of play, millions of Americans who reject it have understandably grown more resentful of elites forcing it down their throats.
The blunder that many of my fellow progressives make is to define the competing point of view as inherently racist or xenophobic. Hazony argues (as Eric Zemour has) that, perhaps ironically, tolerance of minority cultures has historically been a hallmark of nations with an accepted dominant culture. Furthermore, to the degree that globalism or multiculturalism undermine tolerance and cohesion, they destabilize the shared identity of families, tribes, and groups --- the very ties that bind a ‘nation’ together. This tension is clearly evident in Europe, where a growing segment of the citizenry views the European institutions driving the global order as a threat to their own self-determination, impinging on their freedom to chart their own course.
In this light, we should not be surprised at the blistering vehemence of today’s culture wars. One side perceives the other as advocating for a retrograde return to ideals held not by those who won the Civil War, but by those who lost it. The other side perceives an existential threat to the very legacy and tradition that defines a nation.
By Seth David Radwell: Radwell is the author of “American Schism: How the Two Enlightenments Hold the Secret to Healing our Nation” winner of last year’s International Book Award for Best General Nonfiction. He is a frequent contributor as a political analyst, and speaker within both the business community and on college campuses both in the U.S. and abroad.
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Hey Bro! Do You Think Trump Has Your Back?
Sep 14, 2025
This is an open letter to all bros. You're angry. You're disillusioned. And you have every right to be. The question is, what do you do about it? How do you do something that's going to improve your life, your future?
Does the answer lie in a political party? Both Republicans and Democrats certainly want your vote. However, you don't feel that you can look to the Democratic Party for help. They seem to be particularly interested in women, people of color, and immigrants. They haven't spoken to you or done anything for you.
It doesn't matter to you that 100 years ago, they were at the forefront of fighting for American workers against the power of big corporations. They enabled unions to become strong and improve the livelihood of workers. Democrats took action to improve worker safety and a range of other measures that enhanced workers' lives.
"That may be true," you say, "but then Democrats started pushing women's rights and the rights of people of color." Before that, it was mostly a White man's world. Whether you were a blue-collar or white-collar worker, White men were the predominant force. Women and people of color were certainly not a threat.
Now things are very different; you feel that it is you, a White man, who has to fight for what he wants. They say you're privileged because you're White, but as far as you're concerned, what does that matter if you see no way forward for yourself?
The country is at the point now where the White American worker feels neglected by the Democratic Party, and young bros feel like they have not only been overlooked, but they have never had the attention of the Party.
And so when Donald Trump came along and spoke with rage about the plight of the American worker and dissed all the efforts that had been undertaken to help women and people of color through DEI (Diversity, Equity, Inclusion) programs, you understandably listened up and said, "This man is speaking to me."
But wait a minute. Wouldn't you say that all people should be treated equally in the workplace? Should they have the same opportunities? I'm sure your answer is, "yes." But you understandably think it's not fair if some people—women and people of color—are given preference. That's not equal treatment, regardless of how much discrimination there was in the past.
You think Donald Trump may make things better for you? Regardless of what Donald Trump says—he sure does talk the talk—he does not walk the walk; he has done nothing that has or will help you gain strength.
All his efforts against DEI will not change the fact that women and people of color have a different status now than they had 50 years ago. They are and will be your competition. And keep in mind that he isn't attacking DEI to help you; he's just throwing red meat to his manosphere and White supremacist supporters.
To put yourself in the best position possible, you need to acquire the knowledge, talent, and energy necessary to succeed in competition. You can do it. Don't know where to turn? Demand that the government provide you with the resources and opportunity to make the most of yourself.
You have to realize that Donald Trump is a Republican, first and foremost. Certainly not an old-fashioned conservative Republican, but a Republican nonetheless. Virtually everything he has done—all his executive orders, his One Big Beautiful Act—all are for the benefit of the rich and the powerful. He is the friend of the true elite of this country—the big banks and corporations. The Republican Party under President Trump has not become the party of the people, as he and his MAGA allies claim. They have deceived you; they have used you to gain power.
Many of his followers react to the havoc he has created in government with glee because they don't trust government and feel that Reagan spoke the truth when he said, "Government is not the solution; government is the problem." But you have to understand that almost everything Trump is tearing down are programs that helped the average person, not just people of color and women.
Do you know that the majority of people living in poverty in the U.S. are White? That's a fact; not Black, not Hispanic, but White. So all the anti-poverty programs help more White people than people of color. You may not be living in poverty, but consider this. And all the business regulations he's getting rid of—the purpose of all that regulation was to protect the public, the average person—you. However, Trump favors deregulation because it undoubtedly pleases corporations.
So if you can't put your faith in Donald Trump, what about giving Democrats a chance? Don't turn away. You may not have had their attention in the past, but you sure do now! They have heard your complaints loud and clear, as voiced by your vote for Trump.
They are trying to figure out how to provide you with the support you need. Not just to get your vote, but because Democrats have a real concern for the well-being of all Americans. They may have f***ed up at times in the past, but they believe in the words of the Declaration of Independence that all people are created equal and all have the right to "life, liberty, and the pursuit of happiness."
Give them a chance. See how they speak to you. But regardless of how they respond, know that Donald Trump will not only do nothing that improves your position in life, but he also has no interest in you. All he wants is your vote. And everything he says to get your vote is a sham, deceitful.
For both your own sake and the country's, consider what is truly in your best interest.
Ronald L. Hirsch is a teacher, legal aid lawyer, survey researcher, nonprofit executive, consultant, composer, author, and volunteer. He is a graduate of Brown University and the University of Chicago Law School and the author of We Still Hold These Truths. Read more of his writing at www.PreservingAmericanValues.com
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