The U..S House of Representatives passed the Senate-passed version of H.R. 1, the One Big Beautiful Bill Act (although the Senate technically changed the name to "An Act to provide for reconciliation pursuant to title II of H. Con. Res. 14."), on July 3. President Trump signed the legislation into law on July 4. 

Below is a summary of many of the provisions that the Academy has been closely following and we anticipate will have an impact on our members/their patients and communities. If you're interested in understanding further details/comparing to current law, KFF has great articles on the Medicaid, ACA, Medicare, and HSA changes.
Medicaid

• Work reporting requirements: Beginning in 2027, requires states to condition Medicaid eligibility for individuals ages 19-64 applying for coverage or enrolled through the ACA expansion group (or a waiver) on working or participating in qualifying activities for at least 80 hours per month. The legislation includes a list of exempted individuals, such as parents of children under 14 years, caregivers, individuals with a substance use disorder in treatment, and others. It also specifies that if a person is denied or disenrolled due to work reporting requirements, they are also ineligible for subsidized Marketplace coverage. States are not able to waive these requirements.
• Eligibility verification: Requires states to conduct eligibility redeterminations at least every six months for Medicaid expansion adults.
• Retroactive coverage: Limits retroactive coverage to one month prior to application for coverage for expansion enrollees and two months prior to application for coverage for traditional enrollees.
• Provider taxes: Prohibits the implementation of new provider taxes across states, and gradually phases down existing provider taxes in expansion states to 3.5% by FY 2032 (in comparison to the current limit of 6%). The new limit applies to taxes on all providers except nursing facilities and intermediate care facilities, and also applies to local government taxes in expansion states.
• State directed payments: Directs HHS to revise state directed payment regulations to cap the total payment rate for inpatient hospital and nursing facility services at 100% of the Medicare payment rate for states that have expanded Medicaid and at 110% of the Medicare payment rate for states that have not expanded. It does grandfather state directed payments higher than these rates that were submitted prior to enactment of the bill for rural hospitals and prior to May 1, 2025 for all other providers.
• Rural Health Transformation Fund: Establishes a rural health transformation program that will provide $50 billion in grants to states between FY 2026 and 2030, to be used for payments to rural health care providers and other purposes. Uses of funds include promoting care interventions, paying for health care services, expanding the rural health workforce, and providing technical or operational assistance aimed at system transformation. While rural health clinics and community health centers are recognized in the list of "eligible facilities" for payment, standalone physician practices are not. 
• Family planning provider funding restrictions: Prohibits Medicaid funds to be paid to providers that are nonprofit organizations, essential community providers primarily engaged in family planning services or reproductive services, provide for abortions outside of the Hyde exceptions and received $8000,000 or more in payments from Medicaid in 2023. This provision is largely targeted at Planned Parenthood.
• Cost sharing requirements: Requires states to impose cost sharing of up to $35 per service on expansion population adults with incomes within 100-138% of the federal poverty line. It explicitly exempts primary care, mental health, and substance use disorder services from cost sharing, maintains existing exemptions of certain services from cost sharing, and limits cost sharing for prescription drugs to nominal amounts. It also excludes services provided by federally qualified health centers, behavioral health clinics, and rural health clinics.

ACA and HSAs
•    HSA-qualified marketplace plans: Treats individual market bronze and catastrophic plans as an HDHP that can be paired with a health savings account.
•    Direct primary care arrangements: Allows individuals with health savings accounts (HSAs) to use those funds to pay for direct primary care arrangements. This has been a policy that the AAFP has long supported and advocated to both the Internal Revenue Service and Congress to enact. 
•    Telehealth safe-harbor for high-deductible health plans (HDHPs): Permanently extends a COVID-era flexibility that allows sponsors of HDHPs to provide pre-deductible coverage of telehealth services for enrollees.
•    Special enrollment periods (SEP) and tax credit eligibility: Bars anyone who enrolls in a plan via a non-Qualifying Life Event SEP from receiving either premium tax credits or cost-sharing reductions (CSRs) beginning in 2026.
•    Pre-enrollment verification of eligibility for premium tax credit: Requires pre-enrollment verification of eligibility, in comparison to current law where returning enrollees who take no action during open enrollment are auto-renewed into the same or similar plan. 
•    ACA Marketplace coverage eligibility for lawfully present immigrants: Restricts subsidized ACA marketplace coverage eligibility for certain immigrants including lawfully present immigrants who are lawful permanent residents (LPRs or "green card" holders), Compact of Free Association (COFA) migrants residing in the U.S., or certain immigrants from Cuba and Haiti, eliminating eligibility for many lawfully present immigrants including refugees, asylees, and people with Temporary Protected Status beginning January 1, 2027.

Medicare
•    Medicare physician payment increase: Provides a temporary one-year increase of 2.5% to Medicare physician payment rates for 2026.
•    Medicare eligibility for certain populations: Restricts Medicare eligibility to U.S. citizens, green card holders, certain immigrants from Cuba and Haiti, and people residing under the Compacts of Free Association. Eliminates Medicare eligibility for people not included in the above groups, such as those with temporary protected status and refugees and asylees, and terminates benefits for those no longer eligible 18 months after enactment of the legislation.
•    Eligibility and Enrollment Final Rule: Delays implementation of the rule until October 1, 2034, except provisions that have already taken effect, including auto-enrollment of certain SSI recipients into the Qualified Medicare Beneficiary (QMB) group.
•    Nursing Home Staffing Final Rule: Prohibits the Secretary of Health and Human Services from implementing, administering, or enforcing the minimum staffing levels required by the final rule until October 1, 2034.

Other provisions
•    Changes to the Supplemental Nutrition Assistance Program: Prevents any re-evaluations to SNAP benefits beyond inflation, which would not allow SNAP benefits to be updated based on changes to nutritional guidelines. It also implements state-federal cost sharing for states with payment error rates over 6%, which would apply to 47 states.
•    Caps on federal student loan borrowing: Eliminates Grad PLUS loans and caps unsubsidized professional (e.g., medicine) borrowing at $50,000 per year ($200,000 lifetime). The AAFP, both individually and alongside other stakeholders, has strongly opposed this and other student loan-related provisions and expressed strong concern about their potential to further decimate the primary care workforce.

Several other concerning provisions were ultimately removed from the final text, in part thanks to the advocacy of family physicians across the country. This includes recension of the proposal to exclude medical and dental residents from participating in the Public Service Loan Forgiveness Program (PLSF) and banning Medicaid funds from being used to pay for gender-affirming care services for any individuals. 
The AAFP also actively opposed policy within various drafts of H.R. 1 that would have undermined the financial viability of independent practices. The House passed a version of the bill that would have disallowed independent physician practices (and other small businesses deemed as "specified service trade or business") from being able to take advantage of state work arounds for State and Local Income Tax (SALT) deductions if the business were also using small business deductions on pass-through income. The AAFP joined numerous other medical associations in opposing this specific provision in that it would have a detrimental effect on our already diminishing independent practice model for all physicians. This provision was stripped out of the final version.