What the “One Big Beautiful Bill” Means for Digital Health

President Donald Trump signed the One Big Beautiful Bill Act (H.R. 1) into law on July 4, 2025, after razor‑thin votes in both chambers. The law (Public Law 119‑21) is a sweeping tax‑and‑spending package that also rewires major parts of Medicaid, the ACA marketplaces, Medicare, and rural health finance.

Coverage and eligibility will tighten – moving digital tools to the front.
CBO estimates that 11.8 million people will lose health coverage by 2034 due to the law’s health provisions, with total loss potentially reaching 16.9 million when combined with separate policy changes on marketplace eligibility and the expiration of enhanced ACA subsidies. That scale of churn elevates the need for automated outreach, verification, and re-enrollment pathways. (ASTHO)

Medicaid work requirements arrive, phased in from 2026.
States must implement 80‑hour‑per‑month community engagement requirements for able‑bodied Medicaid adults aged 19–64 without dependents, with mandatory exemptions and optional hardship waivers. HHS must issue an interim final rule by June 1, 2026; states must implement this by December 31, 2026, though good‑faith states can be exempted until December 31, 2028. Expect new reporting rails, monthly status checks, and look‑back verification, creating prime territory for API‑driven income and employment data, mobile attestations, and case‑management integrations. (ASTHO)

More frequent redeterminations and stricter verification for coverage.
States must conduct eligibility checks at least every six months, expand use of the SSA Death Master File, prevent duplicate enrollment across states, and lower the home‑equity cap for LTSS. Vendors that can normalize third‑party data, flag discrepancies, and automate notices will be in demand; member‑facing apps will need to reduce friction in document uploads and consent. (ASTHO)

Cuts and copays reshape utilization patterns.
Independent analyses project large Medicaid savings. ABC News reported roughly $600 billion in Medicaid cuts over 10 years, with a CBO estimate reporting that approximately 10.9 million individuals could lose coverage; Democrats also cite nearly 12 million newly uninsured. That pressure, plus new $35 copays for many expansion adults (with key exemptions), could shift demand toward lower‑cost virtual and asynchronous care, if networks remain intact and members stay enrolled. (ABC News, AP News)

Immigration and eligibility restrictions will alter state rolls.
The law narrows categories of non‑citizens eligible for Medicaid and penalizes states that previously used their own funds to cover undocumented residents; it also disallows premium tax credits during periods of Medicaid ineligibility due to alien status. Platforms serving safety‑net clinics should prepare for addressable‑population changes and tailored navigation to alternative coverage or cash‑pay options. (ASTHO, Congress.gov)

Planned Parenthood defunding provision paused by the courts.
The statute blocks federal payments for one year to “prohibited entities” (including affiliates) that perform abortions and received more than $800,000 in Medicaid payments in FY2023. On July 28, a federal judge issued a nationwide preliminary injunction, restoring Medicaid funding to all Planned Parenthood affiliates during litigation, which limits the immediate network disruption, including for gender‑affirming care and STI services. Digital referral and scheduling networks should still map contingencies by state while the case proceeds. (Them)

Rural Health Transformation Program: $50B, with strings and data.
A new five‑year, $10B‑per‑year fund will flow through CMS to states that submit rural transformation plans detailing technology use, workforce strategies, value‑based models, and sustainability metrics. CMS will monitor implementation and “hold states accountable.” Expect RFPs that prioritize remote monitoring, chronic‑care platforms, eConsults, and data pipelines that prove outcome gains and financial solvency. (ASTHO, The White House)

ACA marketplace rules tighten, while telehealth gets a durable boost.
Open enrollment ends a month earlier (Dec. 15), and the year‑round special enrollment for people up to 150% of Federal Policy Level (FPL) ends; the law also heightens Premium Tax Credit (PTC) verification and removes the cap on repayment of excess advance credits. Conversely, it permanently extends the HSA safe harbor for first‑dollar telehealth, allows bronze and catastrophic HDHP‑HSA pairings, and clarifies that direct primary care arrangements are not insurance, opening design space for hybrid HSA & virtual‑first plans and DPC plus wrap coverage. (ABC News, Congress.gov, ASTHO)

PBM reform: House wanted a Medicaid spread‑pricing ban; final law dropped it.
Earlier drafts explicitly prohibited spread pricing and contemplated pharmacy payment surveys. The Senate removed those provisions, and summaries of the enacted law list them among “excluded” items, though other pharmacy payment accuracy language advanced in a different form. For digital pharmacy and transparency players, national spread‑pricing bans aren’t here; expect continued state action and plan‑by‑plan contracting battles. (Politico Pro, Sellers Dorsey)

Moratoria and delays give states time; this should be used to modernize.

The law pauses CMS eligibility rules (Medicaid, CHIP, BHP, Medicare Savings Programs) and long‑term care staffing standards until October 1, 2034. That long runway is an opening for states to rebuild eligibility systems, integrate real‑time data sources, and pilot automation before compliance clocks resume. (ASTHO)

Operational takeaways for digital health entities:

• Enrollment & retention tech: Build configurable workflows for 6‑month redeterminations, work‑hours tracking, attestation nudges, and cross‑state duplicate checks; expose status to members and care teams. (ASTHO)

• Identity, income, and residency verification: Invest in integrations with payroll/HR, credit header, USPS NCOA, SSA Death Master File, and state workforce data; log evidence for audit trails. (ASTHO)

• Benefit design innovation: Leverage the telehealth HSA safe harbor to craft virtual‑first HDHP offerings; pair DPC with wrap benefits and transparent pricing. (Congress.gov, ASTHO)

• Rural pilots with measurable ROI: Target Rural Health Transformation Program (RHTP) RHTP grants with remote monitoring, eICU coverage, behavioral health access, and hospital-at‑home (anchored in outcomes, avoidable transfers, and solvency metrics). (The White House, ASTHO)

• Network continuity risk management: Maintain alternate referral routes in states affected by the defund provision while litigation continues. (Them)

• Policy watch: Track forthcoming HHS rules (by June 1, 2026) and state implementation calendars; product roadmaps should align with the law’s phased deadlines. (ASTHO)

For digital health, the bill tightens eligibility and raises administrative stakes but also codifies telehealth‑friendly plan design and funds rural transformation. Organizations that can reduce churn, verify eligibility cleanly, and demonstrate measurable outcomes, especially in rural care, are positioned to grow.