WASHINGTON — President Donald Trump signed the “Big, Beautiful Bill” into law Friday, triggering a countdown to cuts that will impact many Maryland residents in the coming years.

Republicans passed the legislation Thursday after Congress pulled two all-nighters to meet Trump’s self-imposed July 4 deadline. A host of provisions were included in the spending package; chief among them were the permanent extension of the 2017 tax cuts, new tax breaks on overtime and tips, a $40,000 cap on state and local tax deductions, and $350 billion in funding for border security and defense. It will also make cuts to multiple social programs, including SNAP and Medicaid.

The impact on Medicaid will be particularly significant, with Republican lawmakers cutting roughly $1 trillion from the program over the next decade by instituting more frequent eligibility checks and work requirements, among other policy shifts.

The changes are predicted to cause 11.8 million people to lose their health care by 2034, according to the Congressional Budget Office. In Maryland, roughly 246,000 people are expected to lose their coverage.

Here’s what to know about the Medicaid changes, who they will affect, and when they’ll be implemented.

Increased eligibility checks

A chunk of the savings in the Medicaid portion of the bill will be caused by added red tape that states and residents will have to navigate to determine recipient eligibility.

The new law requires states to increase the frequency of eligibility checks for Medicaid expansion recipients to once every six months. Under previous law, states were required to check eligibility yearly.

The new process won’t be immediately enacted. It will start after Dec. 31, 2026. But once it’s implemented, it will pose an additional obstacle for states and recipients, involving paperwork and logistics.

While some paperwork and some confirmed personal information might sound like a low hurdle to clear, it’s predicted to be a logistical problem. Between address changes, lost mail, and other procedural issues, the Maryland Department of Health predicts roughly 130,000 Medicaid expansion recipients could lose coverage.

Work requirements

For some time, conservatives have viewed work requirements as a way to curtail the high cost of social safety nets. Before Friday, Georgia was the only state with an active work requirement program for Medicaid recipients. That will change Dec. 31, 2026. The new law mandates that expansion recipients in all 50 states be subject to work requirements to receive health care.

People between the ages of 19 and 64, except parents with children 13 or younger or who are pregnant, will have to meet a “community engagement requirement” of 80 hours to maintain or enroll in coverage.

The law will require at least one month of documented community engagement before applying, then an update on a person’s engagement status during their eligibility check.

A recipient must complete 80 hours of engagement to be eligible. Specific things qualify as an engagement that satisfies the requirement: work, community service, enrollment in a work or educational program, or some combination of these that totals 80 hours.

There are exceptions. Anyone with an average monthly income greater than $580 remains eligible, while a state won’t be required to verify the requirements of a recipient with an exemption for a short-term hardship. Hardships include, among others, in-patient hospital services or time in a nursing home or an intermediate care facility. Exemptions are also extended to individuals in counties affected by specific natural disasters.

Recipients who don’t comply with the requirement will receive a notice of noncompliance. If they don’t provide evidence of compliance within 30 days, they can be kicked off Medicaid.

States have the option of implementing stricter, more frequent reports, but not less stringent or less frequent. States can also request a temporary exemption from the program. In that case, the implementation would be delayed, allowing the exempted state more time to build the necessary infrastructure to comply with the law.

An exemption would extend only through 2028.

The nonpartisan Congressional Budget Office and a Georgetown University research professor predict that the work itself won’t be the sole reason recipients lose their coverage; rather, the red tape of reporting their work, or the process of obtaining an exemption, would be the main factor in recipients losing coverage because of the work requirement.

Work requirement programs for subsidized health care in Arkansas and Georgia have experienced mixed results. In Georgia, particularly, its subsidized work requirement program, Georgia Pathways to Coverage, saw high costs paired with low enrollment and technical glitches.

Additional changes

Although it was already federal law that undocumented citizens could not receive Medicaid, the new bill expanded that assertion. Now, states are not allowed to use their own funds to provide health care for undocumented citizens unless they have been admitted as a permanent resident, have been granted protected status as qualified noncitizens, or live in America by a Compact of Free Association.

The law will also impose a two-month cap on retroactive care for children’s health or pregnant mothers who apply for assistance, effective as of Dec. 31, 2026.

Most of the changes have delayed implementation, but not all. As of Friday, certain Affordable Care Act funds would be blocked to facilities that specialize in reproductive health and abortion, such as Planned Parenthood, with limited exceptions — including if the pregnancy is the result of an assault or will endanger the mother. It is a temporary measure that will expire in one year.

Maryland is one of 13 states with laws that require insurers to cover abortion.

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