Sen. Bernie Sanders (I-Vt.) and Rep. Ro Khanna (D-Calif.) introduced legislation March 2 that would reverse the Medicaid and ACA changes enacted under the One Big Beautiful Bill Act and expand Medicare to cover dental, vision and hearing services for seniors.
The “Make Billionaires Pay Their Fair Share Act” would repeal the bulk of the 2025 reconciliation law’s healthcare provisions, effectively reversing impending work requirements for Medicaid enrollees, the tightened eligibility redetermination schedule, restrictions on immigrant eligibility, and new limits on provider taxes and state-directed payments. It would also restore the expired enhanced ACA premium tax credits by removing the 400% federal poverty level income cap.
The bill would pay for its provisions through a 5% annual wealth tax on individuals with a net worth exceeding $1 billion, which Sen. Sanders’ office estimates would raise approximately $4.4 trillion over a decade. Besides the healthcare provisions, the bill would also fund $3,000 per-person direct payments to households earning $150,000 or less, more than $856 billion for affordable housing over 10 years, a $60,000 minimum salary for public school teachers, and a childcare program ensuring no family pays more than 7% of their income on child care.
Medicaid reversal
The proposal arrives as health systems and insurers nationwide have been voicing concern over the financial toll of the reconciliation law on patients and state Medicaid programs. The Congressional Budget Office has estimated H.R. 1 will reduce federal Medicaid spending by $911 billion over 10 years and that up to 10 million people could lose coverage.
State Medicaid budgets will shrink by $664 billion through 2034 as key provisions take effect, with impacts varying by state depending on expansion status, reliance on provider taxes and the use of state-directed payments, according to a RAND study published in February. Meanwhile, Medicaid managed care insurers have been flagging a mismatch between state capitation rates and enrollee acuity over the last couple of years following the pandemic-era continuous enrollment unwinding, leading to negative profit margins in the space.
On the provider side, hospitals could see annual revenue losses of up to $25 billion through Medicaid reductions stemming from the law, according to a September analysis from Kodiak Solutions. The number of uninsured Americans is projected to grow by 14.2 million by 2034 as newly uninsured individuals turn to emergency departments and charity care programs.
King of Prussia, Pa.-based Universal Health Services is projecting ACA exchange volumes will decline by 25% to 30% in 2026 with the expiration of the enhanced premium tax credits, resulting in a $75 million headwind, while Dallas-based Tenet Healthcare is projecting a 20% reduction in exchange enrollment.
Medicare expansion
Beyond restoring the pre-reconciliation Medicaid landscape, the bill would add dental, hearing and vision coverage to Medicare Part B. To prevent a rise in premiums, the bill would phase in the impact of dental coverage from 2027 through 2031.
Dental coverage would include preventive services like cleanings and exams at 100% coverage, along with restorative procedures, root canals, crowns and dentures at 80% coverage. Payment rates would be set at 70% of the national median fee from the American Dental Association’s 2020 fee survey, adjusted for inflation. Providers practicing in health professional shortage areas would receive a 10% bonus payment. The bill would appropriate $900 million for implementation.
Hearing coverage would include audiology services and hearing aids for individuals with moderately severe, severe or profound hearing loss, with a replacement limit of one hearing aid per ear every five years. Vision coverage would include one routine eye exam every two years and one pair of conventional eyeglasses every two years. Combined implementation funding for hearing and vision provisions would total $870 million.
Home and community-based services
The legislation would also invest in Medicaid home and community-based services by offering states an 8-percentage-point increase in federal matching funds for HCBS spending, with an additional 2 percentage points available for states that establish self-directed care programs. States would be required to update HCBS payment rates at least every three years and ensure rate increases translate into proportionate pay improvements for direct care workers.
