President Signs Major Health and Education Law With Sweeping Changes

July 15, 2025

The Big Picture

On Friday, July 4, the President signed H.R. 1, commonly known as the One Big Beautiful Bill Act (OBBBA), into law.
The law makes deep cuts and significant changes to federal programs, including Medicaid and the Affordable Care Act (ACA).
According to the Congressional Budget Office, these changes could result in:
- 12 million people losing health care coverage over the next decade;
- An increase of $3.4 trillion to the national deficit.
Despite the anticipated coverage losses, it includes some positive provisions:
- A one-year 2.5% increase in Medicare payment rates in 2026;
- An expansion of 529 savings plans to include expenses related to postsecondary education, job training, and professional certification—such as licenses and nongovernmental credentials.
ASHA members responded in force, sending more than 32,000 messages to Congress in opposition to provisions such as the Medicaid cuts and other barriers to care.

Register for ASHA’s webinar to learn more about this bill.

Following are the provisions audiologists and SLPs should know related to:

Medicaid
Medicare
The Affordable Care Act
Higher education
Taxes.

Medicaid

Work Requirements

Starting on December 31, 2026, state Medicaid programs must verify that adults ages 19 to 64 are either:

Working at least 80 hours per month; or
Participating in other qualifying activities to remain eligible for Medicaid coverage.

Mandatory Exemptions

States must exempt the following groups from work requirements (not an exhaustive list):

Parents or caregivers of a dependent child ages 13 and under or a person with a disability
Medically frail individuals
Pregnant individuals or those receiving postpartum coverage
Disabled veterans
Dually eligible Medicare-Medicaid beneficiaries
Individuals enrolled in addiction treatment programs.

Each state will handle implementation of these work requirements and exemptions differently.

The U.S. Department of Health and Human Services (HHS) may exempt states from full compliance with these requirements until December 31, 2028, if the state shows a good faith effort to implement them.

What this means: Medicaid-enrolled adults will need to regularly prove to their state Medicaid agency that they work or have an exemption to maintain access to health care, including audiology and speech-language pathology services. This could increase administrative burdens and lead to coverage interruptions for patients.

Eligibility and Enrollment Changes

Before OBBBA, Medicaid allowed states to cover qualified medical expenses incurred up to 90 days before a person applied for coverage. This is most commonly used if there is an unexpected health event that requires enrollment. Under the new law:

Expansion populations can only receive one month of retroactive coverage.
Nonexpansion populations receive two months of retroactive coverage.

OBBBA significantly delays regulations that help reduce barriers for dually eligible Medicaid and Medicare beneficiaries receiving assistance with premiums and cost-sharing. It also requires states to implement more stringent practices for updating beneficiary contact information.

What this means: Delayed and reduced coverage periods create more out-of-pocket expenses, making it harder for vulnerable populations to maintain coverage—directly impacting their ability to access audiology and speech-language pathology services. This means individuals who can’t afford the services will likely go without them or will incur uncovered medical debt in the event of an emergency.

More Frequent Redeterminations

Starting on December 31, 2026, states must conduct Medicaid eligibility redeterminations at least every six months for adults in Medicaid expansion populations.

Even though this requirement targets the Medicaid expansion population, recent experiences during the post-COVID-19 Medicaid unwinding showed that administrative errors caused loss even for populations not directly subject to redeterminations.

What this means: Audiologists and SLPs will see more patients “churn” in and out of coverage. Providers must verify Medicaid eligibility more frequently to avoid uncompensated care.

Cost-Sharing for Expansion Populations

OBBBA imposes mandatory cost-sharing (e.g., co-pays) for Medicaid expansion enrollees earning over 100% of the Federal Poverty Level ($15,650 yearly income for an individual).

Individuals may be charged up to $35 per service.
Services provided by federally qualified health centers and rural health clinics are exempted.

What this means: Cost-sharing, including co-pays, can significantly discourage individuals, particularly those with low incomes, from seeking necessary care. This provision is limited to adult Medicaid-enrolled populations.

Limits on State Provider Taxes

All states (except Alaska) use some form of provider tax to help finance the nonfederal share of Medicaid spending. These taxes are most often levied on nursing facilities, hospitals, and some health plans. Under OBBBA:

New provider taxes are prohibited.
Increases to existing taxes are not allowed.
For states that have adopted Medicaid expansion, the “safe harbor” tax threshold will decrease by 0.5% annually starting in fiscal year (FY) 2028 until it reaches 3.5% in FY 2032. The new limit applies to taxes on all providers except nursing facilities and intermediate care facilities.

States have three fiscal years to transition existing provider tax arrangements that are no longer permissible.

What this means: These provisions will make it more difficult for states to fund their portion of the Medicaid matching rate and could cause states to cut coverage and benefits in order to lower costs.

You can learn more about provider taxes here.

Simplified Enrollment for Out-of-State Pediatric Providers

Previously, providers had to individually enroll in each state’s Medicaid program to see patients who live near them but are across state lines. Under OBBBA:

States must establish a streamlined process for out-of-state providers who service enrollees under age 21.
Enrollment will last for five years, unless the provider is terminated or excluded from participation during that period.
This provision becomes effective in 2029.

What this means: This will ease access to care for children and reduce the administrative burden for audiologists and SLPs providing services across state lines.

Gender-Affirming Care

The final version of OBBBA does not prohibit using Medicaid funding for gender-affirming care.

What this means: Coverage remains in place for gender-affirming services provided through Medicaid—including voice therapy and other speech-language pathology services—if it is permitted by current Medicaid policy in a given state.

Medicare

Temporary Payment Update for 2026

OBBBA includes a one-year 2.5% increase to the Medicare Physician Fee Schedule conversion factor for all services provided between January 1, 2026, and January 1, 2027.

This increase applies to all Medicare Part B services, including those delivered by audiologists and SLPs.

What this means: For one year, Medicare will temporarily boost reimbursement rates for eligible services. However, the increase is short-lived and does not address broader payment adequacy concerns.

No Action on Long-Term Payment Cuts

The bill does not address other budgetary control mechanisms like PAYGO or sequestration that could reduce future Medicare payments.

What this means: Unless Congress acts separately, looming budget rules could still trigger automatic payment cuts—adding uncertainty for providers and potentially reducing Medicare reimbursement over time.

No Extension of Telehealth Flexibilities

OBBBA does not extend Medicare Part B telehealth coverage for audiologists and SLPs, which is currently set to expire on September 30, 2025.

What this means: Unless Congress takes additional action, Medicare beneficiaries will lose access to telehealth services from audiologists and SLPs after that date. This could particularly affect patients in rural or underserved areas and limit care continuity for individuals with mobility or transportation challenges.

Delay of Nurse Staffing Rule

The law delays implementation of the Medicare nurse staffing minimums final rule through FY 2035.

What this means: Although this provision does not directly impact audiologists or SLPs, it could influence broader facility operations and staffing decisions that affect interdisciplinary care settings, such as skilled nursing facilities.

Affordable Care Act (ACA)

Open Enrollment/Special Enrollment Period Preserved

OBBBA does not change the ACA’s open enrollment period for Health Insurance Marketplace plans.

No Changes to Cost-Sharing Reductions

OBBBA does not change cost-sharing requirements for Affordable Care Act plans.

Auto-Renewal

Although OBBBA does not explicitly discontinue automatic re-enrollment, it does impose new pre-enrollment verification requirements that have the same effect. Before an individual can be automatically re-enrolled, the state must verify:

Income
Immigration status
Place of residence
Other personal information.

Currently, 88% of Health Insurance Marketplace enrollees use automatic renewal.

What this means: This change will likely lead to more consumers unintentionally losing coverage, especially those who may not be aware of the new requirements or struggle with documentation. Providers should prepare for increased lapses in insurance among patients who previously relied on automatic re-enrollment.

Premium Tax Credit Enhancement Will Expire

OBBBA does not extend an enhancement to premium tax credits that is set to expire at the end of 2025, which will significantly raise premium costs for Health Insurance Marketplace enrollees.

What this means: Without Congressional action, millions of marketplace enrollees—especially those just above the subsidy cutoff—will face higher premium costs in 2026. This could reduce insurance uptake, limit access to care, and increase financial barriers for speech and hearing services.

Higher Education

Student Loan Borrowing Limits

The bill eliminates Grad PLUS loans and imposes new borrowing caps for graduate and professional school students.

Graduate students are limited to borrowing:

$20,500 per year
$100,000 over a lifetime.

Professional students (e.g., in medical or health professions programs) are limited to borrowing:

$50,000 per year
$200,000 over a lifetime.

Parent PLUS loans reduced annual limits as well:

Annual borrowing is capped at $20,000 per year for each dependent student.
Lifetime borrowing is capped at $65,000 for each dependent student.

The bill also establishes a $257,500 aggregate lifetime loan limit for all borrowers (excluding Parent PLUS loans), regardless of any amounts repaid or forgiven.

Changes to Student Loan Repayment Plans

For new borrowers, the bill eliminates existing student loan repayment plans like the SAVE plan and replaces them with two new repayment options:

Repayment Assistance Plan, which is based on income. The rate would steadily increase from 1%–10% of income over a 30-year term.
Standard Plan, which is based on the amount borrowed with fixed monthly payments.

Pell Grant Eligibility Restrictions

The bill eliminates Pell Grant eligibility for students (and their families) with high enough incomes and assets that their Student Aid Index is twice the amount of the maximum Pell Grant.

For students receiving other non-Title IV grant aid—this would be funds from nonfederal sources like the institution, state, or private source—that combined equals or exceeds the student’s cost of attendance (COA), OBBBA restricts Pell Grant eligibility for “any period” that the student receives grant aid, making the student ineligible to receive a Pell Grant in any amount.

However, this could exclude student athletes with full ride scholarships, institutional merit scholarship recipients, and students receiving grants from free college programs, private foundations, or other entities so long as those funds fully cover the student’s COA (i.e., not just tuition, but also housing, transportation, books, childcare, etc.).

Taxes

Expanded Use of 529 Savings Plans

The bill expands the allowable use of funds from 529 plans to cover qualified expenses to include postsecondary education, job training, and professional and credentialing expenses, such as licenses and nongovernmental certifications.

The bill also expands the use of funds from 529 plans to pay for educational therapies for students with disabilities provided by a licensed or accredited practitioner or provider, including speech-language therapy.

What this means: Families can now use 529 plans to support a broader range of career preparation and developmental services, including therapy provided by SLPs. This may improve access to early intervention services and professional licensing and certification for those entering the field.

ABLE Accounts Made Permanent

OBBBA makes permanent the current provisions for ABLE account contribution and saver’s tax credits that were originally passed as part of the Tax Cuts and Jobs Act.

Creation of Child Savings Accounts

The bill establishes a new child savings account program for children born between January 1, 2025, and December 31, 2028, with a $1,000 deposit from the federal government per child. These tax-advantaged funds can be used for a range of educational and health expenses.

Tax Credit for K-12 Scholarship Donations

OBBBA creates a federal tax credit of up to $1,700 for donation to tax-exempt “scholarship granting organizations” that are recognized by states to provide funding for students to attend K-12 schools. While it prohibits earmarking of contributions for specific students, it is designed to support contributions to organizations providing private school vouchers.

What this means: While this provision may increase access to private schooling for some families, it raises broader questions about equity and potential impacts on public education funding, including school-based speech-language pathology services.

Nonprofit Tax Protections Preserved

The bill preserves the current tax treatment of nonprofit organizations by excluding provisions that would have risked their ability to provide vital resources to meet community needs. ASHA joined the Community Impact Coalition to oppose policies that would have imposed taxes on nonprofit organizations like community hospitals and direct service providers.

What’s Next?

To help members better understand the sweeping implications of OBBBA, ASHA is hosting a free webinar on Tuesday, July 29 at 7:00 p.m. ET.

Join us to learn more about the bill and answer your questions about its impact. Stay tuned for future analyses and webinars on specific topics/issues of interest following enactment of this legislation.