Republicans are quietly rolling back Obamacare. Here's how

CNN

a day ago

President Donald Trump and congressional Republicans are no longer promising to repeal Obamacare, but that doesn't mean they have given up efforts to take down the landmark health reform law.
Unlike in 2017, when the late GOP Sen. John McCain's dramatic thumbs-down dashed his caucus's hope of overturning the Affordable Care Act, Republicans barely mentioned Obamacare as they swiftly pushed Trump's massive domestic agenda package through Congress this year. Instead, they focused their talking points on eliminating fraud in Medicaid and protecting the program for the most vulnerable.
And this time, they were successful in dealing a major blow to the Affordable Care Act. The 'big, beautiful bill,' along with a new rule from the Centers for Medicare and Medicaid Services, is expected to leave millions more people without health coverage, raise costs for those who remain in Obamacare policies, and reverse more than a decade of improvement in the nation's uninsured rate.
In addition, Trump's package is projected to shrink another major provision of the Affordable Care Act — expanding Medicaid coverage to low-income adults — by requiring many of them to work, volunteer or engage in other activities at least 80 hours a month.
'The net effect of the changes they are making is a partial repeal of the ACA,' said Larry Levitt, executive vice president for health policy at KFF, a nonpartisan research group.
What's more, Republicans may further undermine Obamacare before the end of the year if they do not extend the enhanced federal premium subsidies that former President Joe Biden and congressional Democrats approved in 2021. The beefed-up subsidies, which helped propel record sign-ups for Obamacare coverage but lapse at the end of 2025, will be a subject of debate when Congress returns in September.
Democratic lawmakers are already calling attention to the subsidies' expiration, which would send people's premium payments skyrocketing and prompt millions to drop their policies, experts say. Some Republicans have voiced support in exploring the matter, especially since red-state residents would likely be among those losing coverage.
Even though the 'big, beautiful bill' contains the largest-ever cuts to federal support for health coverage, it remains to be seen whether the Republicans' toned-down rhetoric on Obamacare will help them avoid the retribution they suffered in the 2018 midterms, when the repeal effort was a major factor in the Democrats winning control of the House.
'Many of the changes are so technical, it may be hard for the public to grasp what's happening,' Levitt said. 'Many of the changes will take years to take effect.'
Between them, the new law and rule will make it harder to enroll in and renew Affordable Care Act coverage by increasing verification requirements, hiking out-of-pocket costs for enrollees, and banning certain legal immigrants from qualifying for federal subsidies.
The rule is expected to cause up to 1.8 million people to lose Obamacare coverage next year, and the losses will likely be concentrated in seven GOP-led states, including Florida, Georgia, South Carolina and Texas, as well as North Carolina, which has a Democratic governor, according to the Centers for Medicare and Medicaid Services.
Meanwhile, the Affordable Care Act provisions in the law are forecast to lead to 2.1 million more people being uninsured in 2034, according to the Congressional Budget Office.
'It's a radical weakening of what the marketplaces will be able to deliver in the next few years,' said Jennifer Sullivan, director of health coverage access at the left-leaning Center on Budget and Policy Priorities.
But supporters of the Republicans' efforts say the law and rule aim to eliminate many of the expansions and flexibilities in enrollment and verification that Biden introduced into Obamacare, which also opened it up to more fraud, mainly by insurance brokers. (The Biden administration last year took steps to counter an increase in brokers fraudulently accessing and making changes in consumers' accounts without authorization.)
'The One Big, Beautiful Bill restores the ACA, rather than repeals it,' Brian Blase, president of Paragon Health Institute, a right-leaning think tank, told CNN. 'It actually seems like [it's] upholding the integrity of the program.'
'If you can take sort of simple steps like having people every year update their information and having that verified to reduce billions — if not tens of billions — [of dollars] of waste and fraud expenditures, it doesn't undermine the program,' continued Blase, who served as a health policy adviser at the White House's National Economic Council during the first Trump administration and whose work is closely followed by Republican lawmakers.
The law and the rule make sweeping changes to the Affordable Care Act.
Enrollees will be required to verify their income in advance of receiving federal premium assistance to guarantee they are eligible, instead of only reconciling their earnings and subsidies on their tax returns to ensure they received the proper amount of assistance.
Also, they will not be allowed to receive federal subsidies if they fail to file their taxes and reconcile for one year. Plus, if they received too high a subsidy (because they underestimated their income when enrolling), they will have to pay back the entire amount of the excess assistance. Previously, there were limits on the repayment requirement.
The beefed-up verification mandate effectively ends automatic reenrollment in Obamacare, a key method of keeping people covered. Nearly 11 million people — or 45% of sign-ups — were automatically reenrolled for 2025, according to KFF.
The rule also temporarily requires low-income enrollees who qualify for plans with $0 premiums to pay $5 a month until they verify their eligibility. And it allows insurers to require enrollees to pay both initial and past-due premiums before coverage starts.
In addition, it shortens the open enrollment period on the federal healthcare.gov exchange to November 1 through December 15 and requires state-run Affordable Care Act exchanges to end open enrollment by December 31.
The rule also temporarily repeals the ability for those with household incomes at or below 150% of the federal poverty line to enroll year-round, while the law bars those who sign up via certain types of special enrollment periods from receiving federal subsidies.
What's more, the rule makes technical changes that will hike the annual cost of coverage by hundreds of dollars by reducing the premium subsidies and allowing insurers to raise out-of-pocket costs when people receive care. And certain legal immigrants, including refugees, asylees and victims of sex and labor trafficking, will no longer qualify for federal assistance.
The additional documentation and higher costs are expected to lead to healthier enrollees dropping out of the exchanges in coming years, leaving sicker consumers with greater health care needs in the program. That will likely cause insurers to raise their premiums even more or drop out in coming years.
The rule is being challenged in two lawsuits filed by a coalition of Democratic-led states and by a group of cities and organizations, which argue that it will lead to more people losing coverage. That, in turn, will raise the states' and cities' costs for providing health care services to these newly uninsured residents, the plaintiffs say.
The turmoil is already having an impact. Insurers have proposed a median premium hike of 18% for 2026, more than double last year's proposed increase, in part because of the looming expiration of the enhanced premium subsidies, according to a KFF analysis. And Aetna has already announced it will not offer Obamacare coverage next year.
'It will be a tumultuous few years as insurers and people who rely on the marketplace for health insurance ride this out,' Sullivan said.