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On July 4, President Trump signed H.R. 1 (known as the One Big Beautiful Bill) into law. The legislation will have significant effects on education and health care in addition to other policy areas. The law cuts nearly $1 trillion from Medicaid and more than 11 million Americans are expected to lose access to health care by 2034, primarily from loss of Medicaid coverage.

This matters because Medicaid is the single largest mental health care payer in the country — 29% of non-elderly adults with  are on Medicaid and mental health providers receive billions of dollars from the program. Loss of coverage shifts more mental health care costs onto clients, which will be especially difficult for low-income clients.

The legislation will also change borrowing limits for students and redesign repayment plans, potentially transforming higher education.

So, what exactly is in the ‘One Big Beautiful Bill’ and how will it impact counselors? 

Work Requirements

The bill implements work requirements for Medicaid coverage. Starting late 2026, it requires “childless adults and parents of children older than 13 to work, volunteer or attend school for 80 hours a month as a condition of enrollment, unless they qualify for an exception” (). The Congressional Budget Office estimates .

States have previously struggled with adding work requirements to their Medicaid program. Both Georgia and Arkansas experienced logistical difficulties rolling out their work requirement programs, and without increasing the employment rate. Additionally, around procedures despite the fact that they met the work requirements.

In fact, set by the bill. So, health care advocates fear that people will lose Medicaid coverage due to administrative burdens rather than actual noncompliance with work requirements. 

No Subsidies for the Affordable Care Act  Marketplace

The bill did not extend subsidies that have made Affordable Care Act (ACA) Marketplace plans less expensive for consumers and have led to increased enrollment. Without these extended subsidies, �ֲ���ýplan premiums . The end of these subsidies and increases in costs are projected to lead to .

Limited Provider Taxes

The law restricts the use of provider taxes to help fund Medicaid. Provider taxes have been a complicated workaround that has allowed states to get billions in federal funding for Medicaid. New restrictions could, such as reducing Medicaid payment rates or the number of people eligible for Medicaid.

Higher Education and Student Loans

The legislation also makes sweeping changes to the student loan policy and imposes a significant endowment tax on private institutions, especially those with more than $2 million in endowment assets per domestic, tuition-paying student. These institutions will see taxation rates of eight percent.

The legislation also changes borrowing limits for students. The bill levies a lifetime borrowing cap of $100,000 for graduate studies, and a $200,000 cap for those seeking to go to medical or law school. It limits prospects for borrowers who may seek out deferments or forbearance and places new limits on lending for part-time students.

Furthermore, the bill designs new repayment plans for student loans. Going forward, borrowers will be allowed to either repay their loan over 10 to 25 years — regardless of income — or elect to pay according to a structured assistance plan in which borrowers make monthly payments between 1 and 10 percent of their discretionary income. Individuals currently enrolled in the Biden-era Saving on a Valuable Education (SAVE) repayment plan will have to find a new  plan. If they fail to do so before July 1, 2028, borrowers will automatically be enrolled in the Repayment Assistance Plan. 

How These Changes Could Impact Counselors

It will take time to understand and feel the full impact of this law, particularly since elements of it will be phased in over the next few years. However, it’s clear that millions of Americans will lose access to their health care.

With less federal funds to support state Medicaid programs, states may start reducing reimbursement rates, services covered and/or their Medicaid eligible populations. Coverage cuts will be particularly devastating to mental health care, given the oversized role Medicaid plays in covering mental health care.

Overall, this legislation may lead to more people having to pay out of pocket, less people seeking counseling and worsening mental health as people delay care due to cost. It will also disproportionately impact low income and working-class individuals who have depended on Medicaid and the �ֲ���ýmarketplace for access to care.

What Can We Do

During times of setbacks and challenges, it’s more important than ever for advocates to stay engaged and work together to ensure continued access to essential care. We can:

• Encourage legislators to delay implementation of some aspects of this legislation and discourage further cuts to the Medicaid program.

• Helping legislators better understand counseling and its benefits for their constituents can lead to increased funding and protections for mental health care.

• Research has found that meeting with your legislators is one of the most impactful ways to advocate, and it’s an opportunity to channel feelings of uncertainty and stress into productive action.

Stay informed about policy developments and advocacy initiatives

• Attend ACA’s Advocacy Power Hour to discuss policy initiatives, including the Counseling Compact, state-specific policies and the national �ֲ���ýagenda. This monthly forum connects state and regional advocacy leaders with the �ֲ���ýnational team and public policy members.
• Follow �ֲ���ýcommunications for updates about policy impacting counselors.

Follow our Take Action page and participate in campaigns

• The page is regularly updated with new campaigns, ways to share your story and contact information for your legislators

As mental health advocates, it’s essential that we continue to stand up for clients and counselors. Let’s fight for access to these essential services and educate legislators about the dangers of underfunding mental health care.

For any questions or to learn more about ACA’s advocacy efforts, contact us at advocacy@counseling.org