The One Big Beautiful Bill Act and Cancer Care: What Oncology Leaders Need to Know and Do Now

ABSTRACT

The One Big Beautiful Bill Act (OBBBA), enacted on July 4, 2025, represents the most substantial restructuring of Medicaid financing since the Balanced Budget Act of 1997. Key provisions include semiannual eligibility redeterminations for expansion adults,implementation of work requirements no later than January 1, 2027, a $35 per-service cost-sharing obligation for adults with incomes between 100% and 138% of the federal poverty level starting in October 2028, and a freeze on provider tax mechanisms. The Congressional Budget Office projects that these measures will result in coverage loss for 11.8 million individuals by 2034. The Congressional Budget Office estimates that the law will increase the number of uninsured people by 10 million in 2034, relative to estimates made before enactment. These policy changes have direct operational consequences for oncology programs. Multicycle cancer therapy necessitates uninterrupted coverage and continuous prior authorization; any lapse may lead to delayed chemotherapy, abandoned treatment protocols, and poorer clinical outcomes. While prior analyses have addressed the epidemiologic and fiscal dimensions of OBBBA, an operational framework for oncology program administrators and managed care decision makers remains absent. This commentary addresses the gap by presenting a framework grounded in peer-reviewed evidence regarding Medicaid work requirement effects, the impact of cost sharing on cancer treatment adherence, and prior authorization burdens in oncology. The proposed framework encompasses 3 operational domains: proactive financial counseling and eligibility infrastructure, payer mix modeling and scenario planning, and prior authorization workflow optimization. Oncology programs that establish these infrastructures during fiscal year 2026 will be better positioned to manage the coverage transition, whereas those that delay may encounter simultaneous challenges related to patient access and financial stability.

Am J Manag Care. 2026;32(9):484-486

doi:10.37765/ajmc.2026.90003

Takeaway Points

The One Big Beautiful Bill Act implements semiannual Medicaid redeterminations, introduces work requirements no later than January 1, 2027, establishes a $35 per-service cost sharing effective October 2028, and enacts a provider tax freeze, all of which will impact oncology patient coverage. The Congressional Budget Office projects a coverage loss of 11.8 million individuals by 2034, and the Congressional Budget Office estimates that the law will increase the number of uninsured people by 10 million in 2034, relative to estimates made before enactment. Oncology programs are likely to encounter 3 primary operational risks: coverage gaps during treatment, revenue reductions due to shifts in payer mix, and increased stringency in prior authorization processes. A 3-domain framework—comprising proactive eligibility infrastructure, payer mix modeling, and authorization workflow audits—can enhance operational preparedness. Cancer programs that establish this infrastructure in fiscal year 2026 will be better positioned to manage the transition, whereas reactive measures in 2027-2028 are expected to be inadequate.

The One Big Beautiful Bill Act (OBBBA), signed on July 4, 2025, marks the most significant structural change to US Medicaid coverage since the Balanced Budget Act of 1997. Its provisions—semiannual eligibility redeterminations for expansion adults, work requirements implemented no later than January 1, 2027, $35 per-service cost sharing for adults whose income is between 100% and 138% of the federal poverty level starting October 2028, and a freeze on provider tax mechanisms—are projected by the Congressional Budget Office to result in coverage loss for 11.8 million people by 2034.^1,2 The Congressional Budget Office estimates that the law will increase the number of uninsured people by 10 million in 2034, relative to estimates made before enactment.³ For oncology programs, these changes have direct operational implications. Cancer treatment involves multicycle therapy requiring continuous prior authorization, and any coverage gap can lead to delayed chemotherapy, abandoned protocols, emergency use replacing planned care, and worsened outcomes. The operational consequences—including increased uncompensated care, rising bad debt, and shifts in payer mix—warrant proactive management. The policy and epidemiologic scope of OBBBA have been examined, but an operational framework for oncology program administrators and managed care decision makers has not been published. This commentary provides one, grounded in peer-reviewed evidence on Medicaid work requirement effects,⁴ cost-sharing impacts on cancer treatment adherence,⁵ and authorization burdens in oncology.⁶

The 3 OBBBA Mechanisms That Directly Affect Oncology Programs

Semiannual redeterminations impose a structural renewal burden that leads to coverage gaps, even for technically eligible patients. The administrative complexity—such as documenting income, residency, and community engagement activity—often results in lapses for patients with cancer who are functionally impaired by disease burden or treatment adverse effects. Peer-reviewed evaluations of Medicaid work requirements in Arkansas documented coverage loss among eligible enrollees who did not complete documentation requirements, without associated employment gains.⁴ The post-PHE Medicaid unwinding demonstrated the scale of disenrollment associated with renewal and administrative processes.⁷

Cost-sharing expansion presents a direct risk to adherence. The new authority for cost sharing of up to $35 per service may create cumulative financial barriers for some expansion adults, although actual patient exposure will vary by state implementation, covered service, statutory exemptions, and the 5% family-income cap on out-of-pocket costs. Evidence from oral anticancer therapy indicates that higher out-of-pocket costs are associated with prescription abandonment and delayed treatment initiation.⁵

Provider tax and supplemental payment changes further affect facility revenue. OBBBA caps provider taxes at current levels and phases down hold-harmless thresholds in expansion states.¹ For health systems relying on intergovernmental transfers and state-directed payments to supplement Medicaid reimbursement, this results in a direct structural revenue reduction, most severely affecting service lines with a high volume of Medicaid patients.

An Operational Framework: 3 Domains

The Table outlines the framework, including the necessary actions and the anticipated operational impact. Decisions in each domain should be made in fiscal year 2026, not reactively in 2027 when implementation timelines peak.

Domain 1: Financial Counseling and Eligibility Infrastructure

The typical response to coverage churn—increasing financial counseling staff—is insufficient by itself. What oncology programs need is a proactive enrollment system: dedicated financial counselors embedded at each high-Medicaid site rather than centralized, automated eligibility checks integrated into scheduling workflows rather than triggered at the point of service, and a population management dashboard that identifies patients nearing redetermination dates before coverage lapses. Proactive eligibility outreach is a reasonable operational strategy to reduce preventable administrative coverage lapses; programs should measure its effects on midtreatment coverage gaps and authorization failures locally.

Domain 2: Payer Mix Modeling and Scenario Planning

Every oncology program should already have an estimated number of its Medicaid-dependent patients, broken down by treatment phase, primary diagnosis, and facility location. That population serves as the denominator for projecting OBBBA-related financial risk. The planning process is straightforward: Determine the percentage of Medicaid-covered patients likely to experience coverage gaps under conservative, moderate, and severe disruption scenarios; multiply that percentage by the average revenue per encounter type; and estimate bad-debt and unpaid-care exposure accordingly. This analysis guides capital investment in eligibility management infrastructure and provides the foundation for commercial contract negotiations over the next 24 months.

Domain 3: Prior Authorization Workflow Optimization

Enrollment and financing pressures may increase the importance of monitoring payer-specific utilization-management patterns. Oncology programs that have not audited their prior authorization workflows in the past year are operating without baseline denial-rate data at the moment payer scrutiny intensifies. A structured audit documents request-to-approval cycle times, denial rates by payer and drug category, and appeal conversion rates. Prior authorization can delay access to indicated cancer care and imposes substantial administrative burden on patients and care teams.6 Programs should monitor denial rates, turnaround times, and appeal outcomes to identify remediable workflow failures.⁶ Authorization metrics should be monitored as potential indicators of payer-specific coverage and workflow issues.

Implications

Three decisions can be made before the end of 2026: conduct a staffing model audit for financial counseling at all high-Medicaid sites, produce a payer mix baseline report by site and diagnosis to allow comparison against 2026-2027 data, and involve and involve finance leadership in an executive review of the uncompensated care reserve using locally defined low-, moderate-, and high-disruption coverage-gap scenarios. Cancer programs that develop operational infrastructure for the OBBBA environment in 2026 will handle the coverage transition. Programs that delay preparation may face both patient access challenges and financial strain. The impacts are manageable with early planning and cannot be fixed through reactive measures.

Author Affiliations: Department of Supportive Oncology, Atrium Health Levine Cancer Institute, Charlotte, NC; Department of Cancer Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AK); acquisition of data (AK); analysis and interpretation of data (AK); drafting of the manuscript (AK); critical revision of the manuscript for important intellectual content (AK); administrative, technical, or logistic support (AK); and supervision (AK).

Address Correspondence to: Arunkumar Krishnan, MD, MS, Atrium Health Levine Cancer Institute, 1021 Morehead Medical Drive, Suite 70100, Charlotte, NC 28204. Email: dr.arunkumar.krishnan@gmail.com.

REFERENCES

One Big Beautiful Bill Act of 2025, HR 1, 119th Cong (2025). Accessed August 4, 2026. https://www.congress.gov/bill/119th-congress/house-bill/1

Estimated budgetary effects of Public Law 119-121, to provide for reconciliation pursuant to Title II of H. Con. Res. 14, relative to CBO’s January 2025 baseline. Congressional Budget Office. July 21, 2025. Accessed August 4, 2026. https://www.cbo.gov/publication/61570

Health provisions in the 2025 federal budget reconciliation law. KFF. August 22, 2025. Accessed August 4, 2026. https://www.kff.org/medicaid/health-provisions-in-the-2025-federal-budget-reconciliation-law/

Sommers BD, Goldman AL, Blendon RJ, Orav EJ, Epstein AM. Medicaid work requirements­—results from the first year in Arkansas. N Engl J Med. 2019;381(11):1073-1082. doi:10.1056/NEJMsr1901772

Doshi JA, Li P, Huo H, Pettit AR, Armstrong KA. Association of patient out-of-pocket costs with prescription abandonment and delay in fills of novel oral anticancer agents. J Clin Oncol. 2018;36(5):476-482. doi:10.1200/JCO.2017.74.5091

Trapani D, Kraemer L, Rugo HS, Lin NU. Impact of prior authorization on patient access to cancer care. Am Soc Clin Oncol Educ Book. 2023;43:e100036. doi:10.1200/EDBK_100036

Medicaid/CHIP monthly enrollment tracker. KFF. July 1, 2026. Accessed August 4, 2026. https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker/