John McGuire lay there, unable to get up, watching his arm move without him, and slow, and stop.
In 2006, the former Navy SEAL was a self-employed fitness coach. Then, while jumping on a trampoline, he fell.
According to McGuire, his C4 vertebra punctured his spinal cord, paralyzing him from the neck down. At the hospital, he says, doctors said he was unlikely to live through the night.
“It probably took the ambulance five minutes to get to me, but it seemed like maybe longer,” McGuire says, “because I just thought about all the people in my life. I don’t know why, but it just felt like I’d let them down. It’s a real sickening feeling.”
McGuire, now the representative for Virginia’s 5th District, isn’t shy about this story. He’ll talk about his determination to get better and, aside from lingering weakness on his right side, his full recovery. He’ll talk about how God gave him the second chance he used to enter politics.
But no matter how many times you ask, he won’t talk about how much that hospital stay cost, or how he paid for it. Every time C-VILLE asked McGuire about times in his life when health care bills might have presented a burden, he pivoted to a different topic.
In May 2025, McGuire voted yes on HR1, variously known as the One Big Beautiful Bill or the Working Families Tax Cut Act. The bill partially offsets $3.9 trillion in long-term tax cuts with hundreds of billions of dollars in funding cuts and regulatory hurdles designed to reduce Americans’ access to social safety net programs. With tax breaks exceeding its spending reductions, HR1 will add $2.7 trillion to the national deficit by 2034, according to Congressional Budget Office projections.
McGuire says HR1’s cuts help to sustain a system spiraling into uncontrollable costs, by peeling away recipients who don’t truly need the help. He says the bill will supercharge the American economy and open up opportunities to improve on existing programs with new ways for Americans to secure cheaper care.
Experts, social services workers, and people affected by the changes McGuire champions say he’s wrong.
“I don’t actually believe that is what HR1 does,” says Melanie Anne Egorin, an expert in health policy at the University of Virginia’s Batten School of Leadership and Public Policy. “I believe HR1 puts our most vulnerable populations at risk.”
After the Virginia Supreme Court struck down state Democrats’ redistricting plans, McGuire once again became the frontrunner in this fall’s race for his Congressional seat. His vote for HR1 will shape the futures of many of the people and institutions he represents in the 5th District. The bill carries far-reaching ramifications for hospitals, SNAP food aid, individual health care plans purchased through ACA exchanges, and more. Over the next few weeks, C-VILLE will explore these impacts in a series of articles on c-ville.com.
But the most consequential cuts McGuire and his fellow Republicans have passed concern access to health care for some of the poorest Virginians through Medicaid.
Cutting new holes in an old net
“We need a health care system that preserves our citizens’ dignity and independence,” says McGuire. “Of course we need a safety net. But more than that, we need a system that cares for the whole person.”
That system, McGuire says, includes measures that require Medicaid recipients to prove that they’re working. “Work provides stability and better health outcomes and opens the door to millions of Americans to climb out of poverty,” McGuire says. “On the other hand, not working when you are able to leads to a spiral of inaction, government dependence, and feelings of helplessness that become tougher to climb out of.”
Sebastian Tello Trillo, a Medicaid policy expert and associate professor at UVA’s Batten School, says that work requirements for welfare programs like Medicaid have historically tended to cut participation in those programs.
“It’s really hard for a politician to say, ‘We want to reduce enrollment,’ says Tello Trillo. “It’s easier to sell the idea of something like work requirements.”
Rather than spurring people to get jobs, Tello Trillo says most of the available evidence indicates that work requirements drive participants off Medicaid, buried under extra paperwork. “Let’s say you’re sick, and then you can’t work, and so then you can’t get health insurance because you’re sick,” he says. “That part doesn’t even make a lot of intuitive sense.”
The Congressional Budget Office estimates that the bill’s Medicaid changes will leave 7.8 million more people uninsured nationwide by 2034. In the 5th District, the Center for Budget and Policy Priorities estimates that 102,000 people—60 percent of the district’s current enrollees—could lose their coverage in the same period.
A red-tape labyrinth
The expected losses owe largely to HR1’s work requirements for people in what’s known as Medicaid expansion.
Traditionally, Medicaid has covered children, the elderly, the severely disabled, and the deeply destitute. The 2009 Affordable Care Act expanded Medicaid, letting states cover other adults ages 19-64 who make less than 138 percent of the federal poverty line. In Virginia in 2026, that’s $22,025 a year for a single person, or $45,540 for a family of four.
In VA-5, more than one out of every five people receives some form of Medicaid. Around one in every 20 residents is a childless adult on Medicaid expansion. That latter figure works out to more than 39,000 people, enough to fill John Paul Jones Arena more than twice over. Another 11,402 people, comprising 1.5 percent of the district, are parents or caregivers covered by expansion.
With some exceptions—including people caring for the severely disabled, and parents of children age 13 or younger—HR1 demands adults on Medicaid expansion spend 80 hours a month working, studying, or volunteering. Alternately, they can earn an average of $580 per month, equal to 80 hours of federal-minimum-wage work.
To make sure applicants comply, HR1 increases how often they must reapply for health care coverage, from once annually to every six months. That doubles the paperwork burden for patients and state social services agencies.
“That’s where people are going to lose health insurance,” says Egorin. “It’s actually not because they aren’t working. It’s because they have to do the bureaucracy to show they’re working.”
“Here’s the form,” says Gregg Winston, a former hospital administrator who now heads Charlottesville-area nonprofit Move2HealthEquity. He hands over a 16-page booklet packed with blank lines and empty boxes. “And the renewal is essentially redoing this whole thing all over. Yes, it’s very difficult to read. So how in God’s name do you need [16] pages of information in order to certify somebody again?”
In some cases, Medicaid can renew people automatically by cross-checking their data from other government agencies. But Winston says not enough people understand or trust the government to check the box on the application form that permits administrators to do this. His group is training community volunteers to become navigators, helping Medicaid applicants successfully clear HR1’s additional hurdles to receive care.
Even people who do everything right can still lose coverage. For example, Medicaid isn’t allowed to check for forwarding addresses. That means some recipients who’ve moved since their last enrollment miss crucial mailed notices warning them that they need to reapply.
“These are the gigantic holes that people fall into,” Winston says. “They’re still eligible. They still need coverage. But because I didn’t tell you my address, and the law says I can’t forward the information, I can’t go and try to figure out where you are. You get put into the 90-day termination bucket.”
A life on the edge
In September 2025, E.K., 38, had just passed their first anniversary as a senior investing editor for a well-known financial site, making slightly more than $100,000 a year. “I was so, so proud I had cracked six figures,” they say. “I could cry just thinking about that.” (Full disclosure: E.K. is a former colleague of this reporter at a previous employer. They agreed to speak to C-VILLE on condition of anonymity to protect their privacy and their chances of future employment.)
Then Google changed its search algorithm, decimating the site’s traffic. A new CEO laid off around one-fourth of the company. By September 17, E.K. was unemployed.
When they applied for an ACA exchange plan in December, E.K.’s lack of income led Virginia to enroll them in Medicaid instead. By the time they got coverage, “I was already at nearly 100 unsuccessful job applications. I’m over 140 now, and the number would be higher if I wasn’t more busy with the part-time restaurant jobs I’ve been juggling.”
They hadn’t heard about the impending work requirements until interviewed for this article. “If that was what I was walking into when I signed up in December, I would have been at throwing-up levels of anxiety,” they say.
Under HR1, applicants must apply almost immediately upon losing a job; they can’t get coverage unless they show enough income the month before applying. E.K. likely wouldn’t have qualified. Their former employer paid for their health care through last November, and they didn’t need other care until December.
Like millions of Americans, E.K. has chronic conditions managed by medication, including “debilitating” narcolepsy they developed in 2022. “If I don’t take my medications, I can basically go fuck myself,” they say. Their narcolepsy medicine costs $1,000 a month without insurance. “Without it I am completely incapacitated … I cannot safely drive a car or use the stove if I run out of medication.”
HR1’s work requirements exclude people receiving Social Security Disability benefits. But E.K. says getting approved for that status is “notoriously extremely difficult.” Applicants must first demonstrate that their disability keeps them from working for an entire year. Even then, it must appear on the program’s official list of ailments—which doesn’t include narcolepsy. Otherwise, Social Security decides case-by-case whether someone’s sick enough to equal one of its listed conditions.
“I don’t want to prove to some random guy behind a desk somewhere that my condition cripples me without the right medication,” E.K. says.
Until March, when E.K. managed to start cobbling together work, they estimated they spent 14 to 28 hours a week applying for jobs. They’re trying to secure shifts waiting tables, a job they haven’t worked in 15 years, and they’re doing part-time freelance editing work. That should help E.K. meet the hours-worked and income requirements—but only if their jobs don’t fall through.
Collapsing, or not?
“No matter how you slice it, our Medicaid program was collapsing prior to [HR1],” McGuire says. “The reforms we enacted were necessary to ensure the program continues to exist.”
Expansion represented about one-third of Virginia’s total Medicaid spending in 2023. According to the Kaiser Family Foundation, each expansion patient cost the state $8,861 that year. That’s more than the national average for expansion patients, but significantly less than Virginia’s overall average cost of $9,626, and far less than the 10s of thousands of dollars Virginia spent per person to treat disabled and elderly recipients.
“There’s all this money that we’re spending on things like Medicaid, but we are also spending money on a bunch of other things, and we do have money for all those things,” says Tello Trillo. He acknowledges that the program’s overall costs have been rising, and that how to curb those increases, or keep paying for them, are fair questions. But whether we can afford Medicaid, he says, comes down to our priorities.
The Policy Impacts Library measures the fiscal benefits of government policies against their costs. On average, its research estimates that Medicaid expansion returns about 70 cents for every dollar spent. But that represents a range of outcomes. Across all patients, expansion yielded benefits between 60 cents and $1.40 per dollar spent. For families with at least one preexisting condition, the average jumped to 99 cents per dollar spent, with benefits-per-buck between 75 cents and $5.31.
Tello Trillo says that when economists like him consider programs like Medicaid, they ask: Do the long-run benefits exceed the costs? “There’s actually a lot of research that shows that Medicaid provides long-term benefits that offset the cost of the program.” In addition to preventing medical debt and bankruptcy, he says, Medicaid means “people die less.”
After the ACA passed, some Republican-led states refused to expand Medicaid. A 2019 study from the University of Michigan compared death rates between expansion and non-expansion states. Just for low-income people aged 55 to 64, the study found that universal expansion would have saved 15,600 lives across all non-expansion states by 2019.
“When people die less, we think that’s a huge bang for your buck in terms of paying whatever we pay for the program,” Tello Trillo says.
Scapegoats for higher costs
McGuire appears to be using different calculations. “We’re focusing on strengthening Medicaid by ensuring that resources flow to our most vulnerable citizens as originally intended,” he says, “not illegal aliens or able-bodied adults who could work and aren’t contributing their fair share.”
A closer look at McGuire’s criticism of both those groups casts doubt on his accuracy. (C-VILLE invited McGuire and his staff to respond to apparent factual errors or disputed data in his statements, but they declined.)
Immigrants (who aren’t eligible)
Undocumented immigrants—and most legal immigrants—are largely barred from receiving Medicaid. According to the McCourt School of Public Policy at Georgetown University, only “qualified” immigrants, a complex status that includes legal permanent residents, refugees, and asylees, among others, can receive regular Medicaid. Most of that coverage kicks in only after a five-year waiting period.
HR1 strips multiple groups from this pool of legal immigrants, including asylum seekers and most refugees. They also lose access to SNAP, Medicare, and ACA premium tax credits.
By law, hospitals can’t turn people away from the ER. Medicaid reimburses hospitals for undocumented immigrants’ care only when they seek emergency treatment, and only if they meet the same income and other requirements as U.S. citizens.
Between 2017 and 2023, the Congressional Budget Office found that Medicaid spent around $3.85 billion annually on emergency care for noncitizens. That sounds like a lot, but it represented less than 1 percent of overall Medicaid spending each year, including just 0.4 percent in 2023. The U.S. government spent $6.1 trillion in 2023, meaning the $3.8 billion it paid covering Medicaid for noncitizens amounted to around six one-hundredths of a penny per dollar.
HR1 rolls back the amount Medicaid will reimburse states’ emergency care costs to 50 percent. Previously, it repaid some states as much as 90 percent. Those states will have to find ways to cover bigger portions of that bill themselves.
Seven states have also chosen to use state funds only, without federal dollars, to cover Medicaid for every eligible resident regardless of immigration status. Virginia isn’t one of them.
Able-bodied adults
“Unemployed adult Medicaid recipients who are able to work are spending an average of 44 hours a week watching TV or socializing,” McGuire says, “and spend less than an hour a day looking for work or caregiving.”
That frequent Republican talking point comes from a 2025 study by the conservative American Enterprise Institute, which says that “non-disabled” expansion recipients who aren’t working or in school spend 6.1 hours a day on leisure activities.
Critics say that study defined “disabled” too narrowly, including only about 14 percent of Americans with disabilities. Many of the rest may be healthy enough to work some of the time, but still physically incapable of full-time work.
“Most people that are already receiving these welfare programs are actually already working,” Tello Trillo says, “and if they’re not working, it’s most likely due to a particular reason, like a disability, sickness, a lot of challenges in their life that led them to not have consistent employment.”
Per a 2025 study by the progressive Urban Institute, only 2 percent of respondents simply chose not to work. That translates to roughly 300,000 people out of the 15 million in expansion nationwide. Sixty-nine percent of enrollees were working or attending school, though 23 percent would have missed at least one month of income requirements under HR1. Another 21 percent weren’t working because they physically couldn’t, were struggling to find a job, or had someone at home who needed their full-time care. Those national figures line up with local observations. “Seventy percent of the Free Clinic patients work,” says Willa Barnhardt, executive director of the Charlottesville Free Clinic. “The ones that don’t work are trying to find work.” The clinic mostly serves people without any health care, including Medicaid. In its most recent annual survey, patients listed 561 different employers.
“They’re still wearing maybe their uniform from … a paint crew, or from the grocery store, and they still have their hairnet from working there all day,” Barnhardt says. “They need health care. And if it’s not Medicaid, then it’s going to end up being free clinics, or the emergency room.”
E.K. says they’ll go back to full-time employment in a heartbeat, if they can only find a job. ”I want to not worry about my savings draining away as I continue to bring in less money than what covers my rent payment, let alone groceries and other essentials. I do want a paycheck. I want to feel even a little bit more secure.”
When work requirements don’t work
Two states previously tested work requirements for Medicaid. The results appear to have been a failure at best—and disastrous at worst.
Georgia declined to expand Medicaid under the ACA, instead creating Pathways to Coverage in 2021. It offers Medicaid-like care for patients at or below the federal poverty line, with work requirements like HR1’s. In 2022, Gov. Brian Kemp estimated that 345,000 Georgians would be eligible for the program. By February 2026, only 14,952 people had successfully signed up.
A 2025 review from the Government Accountability Office found that between 2021 and mid-2025, Pathways spent twice as much on administrative costs as it did actually providing care: $54.2 million versus $26.1 million.
Arkansas’ earlier experiment had grimmer outcomes. Between June 2018 and March 2019, the state tested work requirements for Medicaid recipients ages 30-49 living below the poverty line. Thanks partly to a poorly designed system, 18,164 people in Arkansas lost health care. Only 1,981 found any kind of new job. State data didn’t record whether those jobs were full or part time, or how long they lasted.
During Arkansas’ experiment, Harvard researchers surveyed the people losing care. Getting kicked off Medicaid didn’t spur people to find work; it cost them jobs. The percentage of people employed for at least 20 hours a week fell by 3.5 percentage points, from 42.4 percent to 38.9 percent.
McGuire acknowledges the failures of past work requirement programs, but says this time will be different. Requirements will be standardized across states, he says, preventing “clunky or inconsistent rollouts.” Enrollees get a three-month grace period to adapt to the new requirements. And states can delay implementing them up to December 31, 2028 (after the next presidential election), as long as they show they’re working on it.
Tello Trillo says there are ways the government could make Medicaid more effective and cost-efficient: Expand access to telehealth and other forms of preventative care, incentivize more providers to accept Medicaid patients, and remove red tape and its overhead costs.
“This bill, unfortunately, doesn’t do any of those things,” he says.
Help, health, and history
Tragedy haunts every branch of McGuire’s family tree. Public records and newspaper accounts show that two of his mother’s younger siblings died in accidents—one drowning, one fatally injured in a car crash—before their 19th birthdays. In 1989, McGuire’s uncle, living with severe untreated mental illness and convinced he was hearing the voices of angels, murdered McGuire’s maternal grandfather with a shotgun blast to the face.
According to public records, McGuire’s mother, Bessie Louise Heath, was first married at 17, deserted and divorced with two children by 20, and remarried by 22, in August 1967. Her new husband, John McGuire, Jr., was 33.
McGuire says his parents struggled with substance abuse, leading him to shun drugs and alcohol. By his hazy recollections, after his father left in 1972 and his parents officially divorced in 1975, his mother left McGuire and his sister on a street corner when he was 5.
After years in the foster system, McGuire says he and his sister were rescued by his paternal grandparents. The congressman still speaks of his grandfather, John McGuire Sr., a Navy veteran of World War II, with reverent love.
“He was a very strong man,” McGuire recalls. “We would go to the beach and he would swim straight out and disappear and come back … I didn’t have a watch when I was a kid, but it seemed like hours later.”
According to state records, McGuire Sr.—then a maintenance worker for Richmond Public Schools—died of lung cancer in 1982 at age 62. McGuire was 14 years old. “I remember I didn’t want to go to school that day,” McGuire says. “I just felt like something was wrong. And sure enough, he passed away when I was at school.”
Asked about the burden, financial or otherwise, that death might have placed on his family, McGuire says, “When you’re young, you don’t share financial burdens with a kid. But to be honest, I wasn’t very aware of that. But was it a challenge? Certainly, it’s a challenge.”
Then he changed the subject.
Next week: Virginians face another price shock, as McGuire’s HR1 vote drives up the cost of health care plans on ACA exchanges.
