After the passage of last year's so-called "One Big Beautiful Bill Act" (also known as H.R.1), I started joking that this administration was the best innovation partner our company has ever had. Every time they do something harmful, we take it as a challenge and start working on products or services we can build to ensure the people who need help the most actually get it.
In the same joking-but-not-really manner, I've taken to calling it the Big Ugly Bill Act, or BUBA. Not just because it's a more honest acronym, but because "Bubba" — as in the everyman this legislation claims to champion — is exactly who it's going to hurt. Not Democrats. Not Republicans. Everyday Americans in every state, in every kind of community.
Last week's CMS interim final rule made the joke more real — and a lot less funny.
What the Rule Actually Does
The rule lays out the implementation details for one of H.R.1's most consequential provisions: new Medicaid "community engagement requirements," the policy world's euphemism for work requirements. To understand why this matters, a little context: about 75 million Americans are on Medicaid. Roughly 20 million of them are in what's called the adult expansion group — non-elderly, non-disabled adults, ages 19 to 64, who gained coverage through the Affordable Care Act's Medicaid expansion. They're the people H.R.1 specifically targets. Starting January 1, 2027, they'll need to document 80 hours a month of qualifying activity — work, school, caregiving, community service — or risk losing their health coverage.
The Premise vs. the Facts
The premise behind all of this is that people who need help simply don't want to work; that they just need to get it together and climb the economic ladder. But the facts tell a different story. Of those currently on Medicaid, 64% already work full or part time, and those who don't are mostly caregivers or students. So why do those 64% even qualify for Medicaid if they're working? Because a full-time job at the federal minimum wage pays about $15,000 a year while the national living wage for a single adult is approximately $40,000.
Structurally, the deck is already stacked against millions of people in this country. Rather than addressing that, H.R.1 adds another layer of complexity on top of it – not by taking away eligibility directly, but by burying eligible people in paperwork. The research bears this out: between 5 and 10 million people could lose coverage, most of them not because they don't qualify, but because they can't navigate a reporting process that assumes a stability of employment and documentation that their lives simply don't afford.
That not only keeps me up at night, but it also makes me want to tackle the problem even more aggressively in the morning.
Where the Work Is
At ITO Health, we're building tools to close exactly this kind of gap: the distance between what people are entitled to and what they can actually access. H.R.1 creates a specific, brutal version of that gap on a tight timeline, and we are working to address it. Not because we think this is good policy — we don't — but because the people caught in it deserve better than to lose their health coverage to a bureaucratic process they didn't know was coming.
This administration didn't intend to be an innovation partner to companies like ours. But crises have a way of clarifying what matters. Just as bad policy can reveal what good policy could or should do, it can also show you exactly where the work is. H.R.1/BUBA is bad policy that shows us exactly what our work needs to be: helping to ensure that all Americans have a fair shot at the healthy life they deserve.