The Big Beautiful Blunder
The Budget Reconciliation Bill
as It Affects Nursing Homes and the Poor
C. Gourgey, Ph.D.
On the afternoon of July 3, 2025 Congress passed the “Big Beautiful Bill” that will cause great harm to our most vulnerable. As an advocate for nursing home residents, I especially want to show how this bill will affect nursing homes and the people we love who live in them, as well as care for the elderly and disabled in general. So I will outline some of the salient points below. Nevertheless, this brief summary does not exhaust the ways this bill will hurt those in our society who can least afford it.
The cuts to Medicaid prescribed by this bill constitute the largest slashing of health care in the history of this nation. The bill specifies over $800 billion in Medicaid cuts over the next ten years. Over 60% of nursing home residents depend upon Medicaid. These people will likely be affected by staffing cuts and a reduction in services provided.
A much greater burden now falls on the states, which do not have the resources to make up the shortfall. States will have to cover more costs or cut services. Medicaid reimbursement rates will drop, and HCBS (home/community-based services) are in danger of serious reduction or elimination. This affects nursing home residents too: many nursing home staff rely on these Medicaid services, and it will be harder to retain these people if these services are cut. Compounding the problem, the bill delays implementation of the federal staffing mandate for 10 years, effectively killing it. Nursing homes are already understaffed, and residents will be placed in even greater danger. Facilities will have more difficulty meeting their responsibilities. Some are already anticipating service cuts or even closure.
One serious provision that has attracted little attention is shortening Medicaid’s retroactive coverage period from 90 to 30 days. This will adversely affect residents just applying for Medicaid, and especially those admitted to nursing homes under Medicare who must apply for Medicaid once their Medicare coverage lapses - often an unanticipated and time-consuming necessity undertaken at the last minute. Many people do not realize that after three months Medicare coverage of nursing home services stops completely - if one requires a longer stay one must either pay out of pocket or apply for Medicaid. Applying for Medicaid takes time. The cost of any services received between the end of Medicare coverage and the start of Medicaid may no longer be fully covered.
States stand to lose billions in federal health funding, straining both hospitals and nursing homes. Job losses at hospitals will come at a time when many who are thrown off Medicaid will have to make greater use of emergency rooms, which are already understaffed. This will affect all of us. Hospitals are overcrowded as it is, and this will greatly increase the strain on them.
It is projected that millions will lose their health coverage because of this bill. Reporting requirements have been toughened, made more frequent and complicated, the idea being to make it easy to kick people off the rolls who fail to comply with arcane paperwork they do not understand. And yet this bill will balloon the deficit. So much for “fiscal responsibility.”
I should not conclude without a word on immigration. One can make a case that Biden’s policies on the border were too lax. That still does not justify the hysterical Republican overreaction. Republicans have successfully played on people’s fears to promote an agenda of hatred and cruelty, as if everyone who comes here from another country is a gang member and must be eliminated. This too will affect nursing homes (not to mention our society as a whole). Immigrants trying to comply with the law are being snatched while showing up for their mandated appointments. Families are being disrupted again.
The current administration has virtually criminalized the asylum process, which should remain a legal way for people to apply who face dangerous and life-threatening conditions in their home countries. I worked with some of these when I was Long-Term Care Ombudsman at a hospital that served many of them. Cutting off all legal recourse to these people is inhumane and unconscionable. So is the attack on Temporary Protected Status programs and DACA (Deferred Action for Childhood Arrivals). We have (or have had) many talented DACA people in this country, who were brought here as children and who will not be graciously accepted by the countries to which they will be sent, countries whose cultures they do not know and whose languages they might not even speak. We need these people and the contributions they make to our society - yet many are now self-deporting. Trump’s anti-immigrant rhetoric alone may dissuade many talented people from coming here - and this while nursing homes in New York become increasingly dependent on immigrants to meet their staffing needs.
So what does the “Big Beautiful Bill” do to address this? It provides $45 billion for immigrant detention centers, while not one penny for what we really need: more immigration judges and courts to adjudicate applications and asylum claims. This country would be nothing without immigrants. My parents were immigrants, and I cannot be sufficiently grateful to them for the sacrifices they made and the example they set. The current administration’s fomenting hatred against all immigrants to consolidate its own power brings out the worst in all of us.
And while not directly affecting nursing home residents, the new work requirements that this bill imposes (the vast majority of Medicaid recipients who can work already are) and the extensive cuts to food stamps seem especially vindictive, gratifying the resentment many feel toward people who need these benefits. Finally, in an especially cynical move, some of the worst provisions of this bill will not take effect until after the midterm elections, when it will be too late to take corrective action. This only indicates that on some level the bill’s framers realize how poisonous it is.
The Republican Party has betrayed the American people, all to enrich those who have more money than they will ever spend, at the expense of those who most need our care. This bill takes money from services to the poor in order to fund tax cuts for the wealthy. It is a massive transfer of wealth from the poor to the rich, based not upon a concern for the greater good but on a policy of resentment and greed. It appeals to the worst in our nature, and contributes to the increasing heartlessness of our society. And it will define who we are, unless enough people protest.