Sexual and Gender Minority Medicaid Recipients’ Reactions to the One Big Beautiful Bill Act: Implications for Social Work and Social Policy

Background and Purpose: Medicaid is a critical safety net program that shapes access to healthcare and material resources for marginalized populations in the United States. For lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender minority (LGBTQIA+) individuals who experience disproportionate rates of poverty, employment instability, and discrimination, Medicaid plays a central role in mitigating structural inequities and supporting health and well-being. Social work scholarship emphasizes the importance of examining how policy changes reproduce or disrupt these inequities, particularly for populations at the intersection of multiple forms of marginalization. The One Big Beautiful Bill Act (OBBBA) proposes substantial changes to Medicaid financing and eligibility that may exacerbate existing disparities. This study aims to understand the current and anticipated impacts of the OBBBA on LGBTQIA+ Medicaid recipients with attention to how policy shifts shape lived experiences, access to care, and broader social determinants of health.

Methods: Participants were purposively recruited from The PRIDE Study, an online, national, community-engaged, cohort study examining LGBTQIA+ adult health. We conducted semi-structured, virtual interviews with LGBTQIA+ Medicaid recipients in the United States from June-August 2025. Interviews were transcribed and analyzed using qualitative description as a guiding methodology to provide rich, common language, phenomena summaries grounded in the words of participants. Structured memos, coding, group discussions, and writing were used as analytic strategies to generate themes.

Results: Participants (n=29) were diverse with respect to age, gender, sexual orientation, ethnoracial identity, and disability. We identified five themes: (1) elitist, untrustworthy, and discriminatory views of government, in which participants described funding cuts as eugenics programming targeting transgender people, people living with HIV, and people with disabilities; (2) barriers with system navigation, where participants felt overwhelmed by administrative requirements and anticipated new requirements to demonstrate Medicaid eligibility; (3) fear of losing lifesaving resources, including access to chronic disease treatments such as HIV medications; (4) adverse mental health and well-being impacts from anticipated financial insecurity and loss of access to life-saving care; and (5) protective survival responses amidst compounding structural oppression, where many participants were engaged in activist work or informal employment to meet personal and community needs.

Conclusions and Implications: Findings highlight how anticipated Medicaid policy changes are experienced as forms of structural vulnerability that compound existing inequities for LGBTQIA+ populations. From a social work perspective, these results underscore the role of policy as a fundamental determinant of health and the importance of centering lived experience in evaluating policy impacts. Participants’ narratives illustrate how administrative burden, stigma, and resource insecurity operate as mechanisms through which policy changes translate into adverse health outcomes. Social workers across clinical, community, and policy settings are uniquely positioned to mitigate these harms through advocacy, policy engagement, and the provision of affirming, resource-oriented care. These findings call for strengthened social work involvement in Medicaid policy debates, the development of interventions to support navigation and continuity of care, and collective action to protect and expand access to healthcare for LGBTQIA+ communities.