One Big Beautiful Bill Act Doesn’t Spare Cardiology

The One Big Beautiful Bill Act (OBBBA), recently passed by the US Congress and subsequently signed into law by President Donald Trump, is expected to have long-lasting effects for hospitals, practices, clinicians, and patients—including those in cardiology.

Overall, the law is expected to cut $1 trillion in funding to the Medicaid program over the next 10 years and make substantial changes to the student loan program. Together, these provisions could jeopardize patient access to care and test the strength of an already-strained clinician pipeline. 

Leading up to the passage of the bill, the American College of Cardiology (ACC) remained proactively engaged as the reconciliation process unfolded: activating our grassroots networks at key moments in the process, identifying opportunities to engage with lawmakers, and remaining vigilant in our efforts to ensure the voice of cardiology was heard clearly on Capitol Hill.  

Medicaid Cuts Loom

As the deadline for implementing the Medicaid provisions approaches, states face the challenge of either securing additional funding to sustain current services or reducing or even eliminating access to services. Approximately 28% of adults covered by Medicaid have a history of cardiovascular disease and nearly 62% of adults 18-65 years old have at least one chronic condition, including cardiovascular disease. Heart disease remains the leading cause of death in the United States, and the cuts to the Medicaid program may lead to more people relying on emergency services in place of routine preventive care. Prevention is essential for cardiovascular care, and without it, healthcare costs are likely to keep rising, ultimately harming patients the most. 

Another important aspect of the Medicaid cuts that cannot be overlooked is their potential impact on rural hospitals. The Cecil G. Sheps Center for Health Services Research estimates that more than 300 rural hospitals could be at risk of closing due to the high volume of Medicaid recipients they treat, years of negative total margins, or both. A report released in JACC in November 2024 found that cardiovascular death rates were consistently higher in rural areas—up to 1.5 times higher in 2022—compared to urban or other metropolitan areas. Although Congress allocated $50 billion for a rural hospital transformation fund as part of the OBBBA, this amount is likely insufficient to bridge the gap created by the $1 trillion in cuts. 

Pressure on the Clinician Workforce

On the student loan front, one of ACC’s key advocacy priorities is bolstering the clinician workforce, something that could soon be compromised. The bill caps student-loan borrowing limits for professional programs at $200,000, falling short of the average cost of attending medical school, estimated at $235,000. Additionally, it eliminates the Grad PLUS program, leaving prospective medical students with fewer options to finance an education that pays societal dividends by safeguarding the heart health and safety of Americans nationwide. 

A study published by the National Center for Health Workforce Analysis projects that the US will face a shortage of up to 8,650 cardiologists by 2037. This reality presents a significant challenge for an already-burdened workforce. A survey conducted during the pandemic revealed that 59% of cardiology nurses, 46% of cardiovascular team members, and 40% of physicians reported experiencing burnout. Further reduction of this workforce will likely worsen clinician well-being and impact efforts to recruit and retain staff. 

On the patient side, although deaths from heart attacks have decreased over time, the number of patients who present with risk factors for cardiovascular disease is rising. A robust cardiovascular clinician workforce is critical to improve patient outcomes and reduce these alarming statistics. Limiting funding options for prospective medical students may jeopardize the progress made in modern medicine. 

In grassroots messages sent to lawmakers, ACC members have shared that the high cost of attending medical school is a significant barrier for many aspiring cardiologists. Without the necessary loans to cover these expenses, many individuals may not have the opportunity to attend and provide care in their communities, potentially exacerbating disparities for underserved populations. Currently, nearly 50% of counties do not have a cardiologist, resulting in millions of Americans with limited access to the care they need. 

Limiting funding options for prospective medical students may jeopardize the progress made in modern medicine. William A. Van Decker

The timeline and specifics of how these cuts will be felt remain uncertain. Legislation, like the Protect Medicaid and Rural Hospitals Act, has already been introduced in the US Senate aiming to scale back some of the Medicaid provisions. ACC will continue to monitor the landscape within Congress and state legislatures, and we will engage with our membership and chapter leadership accordingly. 

Following the conclusion of the reconciliation process, the College plans to build upon several provisions in OBBBA to advance key issues, including an immediate need to address telehealth flexibilities within Medicare and a long-term goal of achieving Medicare payment reform.  

Lawmakers included a provision in the new act to broaden access to telehealth services, making permanent a pandemic-era provision that allowed individuals with high-deductible health plans to access covered telehealth services without first meeting their deductible. This acknowledgement of the advantages of innovative, modern services is appreciated, and we hope to leverage this momentum to extend or make permanent existing telehealth flexibilities within Medicare. The continuing resolution Congress passed in March extended these flexibilities until September 30, 2025. Without further congressional action, though, they will expire, disrupting access to cardiovascular care for our nation’s most vulnerable seniors.

Challenges in Medicare Payments

In addition to the pressing issue of telehealth, we must also address broader challenges within the Medicare payment system. The OBBBA included a 2.5% update to the conversion factor in the Medicare Physician Fee Schedule (MPFS) for 2026, but it is merely a temporary fix to a larger systemic issue. Additionally, a -2.5% efficiency adjustment was included in the CY 2026 MPFS proposed rule nearly nullifying this update. However, the inclusion of an update for 2026 is a step toward engaging lawmakers in a larger discussion about creating a sustainable Medicare payment system. MEDPAC has also recently recommended tying physician payment updates to the Medicare Economic Index to better keep pace with the rising costs of delivering care. 

Last Congress, several bills were introduced that sought to introduce longer-term legislative solutions for Medicare reimbursement. The Strengthening Medicare for Patients and Providers Act would have added annual inflationary updates to the MPFS tied to the Medicare Economic Index. Additionally, the Provider Reimbursement Stability Act in the US House and the Physician Fee Stabilization Act in the US Senate would have increased the budget neutrality threshold from $20 million to $53 million. Notably, this threshold has not been increased since it was first introduced in 1989.  

These pieces of legislation are examples of the precedent the last Congress set in seeking commonsense legislative solutions to remedy the nearly 33% decrease in physician payment over the last 20 years when adjusted for inflation, at a time when practice expenses have risen by more than 60% during the same period. Clinicians cannot continue to absorb these cuts without facing serious financial repercussions, which ultimately threaten patient access to care. 

As we move forward in our mission to transform cardiovascular care and improve heart health for all, we will continue to constructively engage with policymakers and leverage the collective efforts of the broader medical community. Together, we can create a sustainable system that rewards value, promotes high-quality care, and prioritizes patients in health policy discussions. 

Off Script is a first-person blog written by leading voices in the field of cardiology. It does not reflect the editorial position of TCTMD.