The latest iteration of the One Big Beautiful Bill would increase hospitals’ annual uncompensated care costs by tens of billions of dollars in the coming years, according to a policy brief from America’s Essential Hospitals (AEH).

Specifically, in 2034, the group said total uncompensated care costs would rise by at least $42.4 billion from 2025’s estimated baseline—$21.7 billion from Medicaid payment shortfalls and $20.6 billion from caring for the uninsured.

The projected cost increases for hospitals would generally increase with each year, with a particularly substantial jump as 2027’s roughly $10 billion total more than doubles in 2028.

The AEH said those reductions would “disproportionately harm” the safety net hospitals, disproportionate share hospitals and others the lobbying group characterizes as essential hospitals. About three-quarters of these hospitals’ patients are either uninsured or covered under government programs.

“Although essential hospitals account for just 5% of hospitals nationally, we estimate that they would bear approximately 25% of the added hospital unpaid costs of care,” the group wrote Thursday. “This would amount to an additional $10.7 billion in cuts to essential hospitals in 2034.”

The group’s analysis is based on multiple Congressional Budget Office (CBO) projections of the bill’s impact as passed last month by the House of Representatives. This includes a Wednesday report predicting 10.9 million people would no longer have health insurance in 2034 under provisions of the current bill—though recent amendments to push up the implementation date for Medicaid work requirements to Dec. 31, 2026, are not reflected in the AEH’s projection.

The AEH also relied on information from the Centers for Medicare & Medicaid Services and the Medicaid and CHIP Payment and Access Commission to estimate the extent to which the bill’s limitations on state directed payments—both a moratorium on provider taxes and a freeze holding state directed payments at existing levels—would affect hospital payments.

The AEH noted that the provisions related to state directed payments “will likely compound over time because these proposed Medicaid payment freezes do not appear to fully keep up with inflation.” The group’s estimate primarily looked at the state directed payment provisions and does not include some that could affect Medicaid payments, such as modifications to some cost sharing requirements, or consider whether limits on federal Medicaid funding to states could constrain state’s ability to continue paying for hospital services.

The reconciliation bill is currently being debated in the Senate, where it is certain to face changes, with the updated version then requiring another sign-off from the House. Republican lawmakers and President Donald Trump have said they hope to pass the package no later than July, though fractures have appeared between fiscal hawks and those whose states would be hit hardest by Medicaid cuts—and more recently, between the president and influential billionaire Elon Musk.

Also at issue for hospitals and payers alike are premium tax credits for marketplace plans set to expire this year. Wednesday’s CBO projections estimated 4.2 million more people would be without health insurance in 2034 should they not be renewed. Hospital groups and health system leaders have included tax credit extensions alongside recent months’ advocacy for smaller cuts to Medicaid.