Shhh. Republicans are trying to repeal Obamacare again. Sort of.

Washington Post

02-06-2025

Congressional Republicans are pursuing changes to the Affordable Care Act that would mean 10.7 million fewer Americans using its insurance marketplaces and Medicaid, a huge reduction that some view as a way to accomplish part of the health-care coverage cancellation that failed in 2017.
They're not branding it a repeal of President Barack Obama's signature health care law this time around, and this year's effort wouldn't erase its marketplaces or Medicaid expansion. Congress tried that the last time President Donald Trump was in office but abandoned it amid an outcry from the health care industry, advocates and voters.
But the GOP plan making its way through Congress would sharply increase the number of people without health insurance, largely by narrowing the path for poor Americans to gain coverage and making it easier for them to be booted off it. It would target the twin pillars of Medicaid expansion and federally subsidized insurance marketplaces, with new rules Republicans say will reduce waste, fraud and abuse.
That's a notable departure from the Obamacare repeal-and-replace Republicans pursued for years, but an approach that still undermines the law's broad goal of getting most Americans covered.
'It is very much like a backdoor repeal and replace,' said Matt Salo, former executive director of the National Association of Medicaid Directors and now a health-care consultant. 'They've been too cute by half by doing it but not calling it that.'
Animosity toward the Affordable Care Act, which still exists among some Republicans, isn't what gave rise to this latest slate of proposed cuts. Rather, it was the need to help pay for extending Trump's tax breaks in the budget reconciliation bill the president has urged them to pass this summer.
House Republicans managed to find more than $800 billion over 10 years in savings from Medicaid and the marketplaces in a bill they passed last month, which is now under consideration in the Senate. The Congressional Budget Office has estimated that should their bill become law, 7.6 million fewer people would be enrolled in Medicaid and 3.1 million fewer would be enrolled in the marketplaces than would be on the rolls a decade from now.
'They're not calling this ACA repeal and replace, but the coverage losses would be among many of the same people who would have lost their insurance under ACA repeal,' said Larry Levitt, executive vice president for health policy at KFF.
States would face new mandates and restrictions under the GOP bill. They would need to verify Medicaid expansion eligibility every six months instead of once a year. They could no longer sign up the lowest-income marketplace enrollees throughout the year. They would have to collect more paperwork from certain marketplace applicants. The open enrollment period would be shortened by a month.
The bill would also delay two Biden-era regulations aimed at easing and streamlining enrollment by helping people more easily transition between Medicaid and Children's Health Insurance Program and private marketplace plans.
Taken together, those changes would amount to the biggest slash in enrollment since repeal failed eight years ago.
States would face a steeper burden in administering their Medicaid programs and marketplaces, resulting in eligible people losing coverage, said Edwin Park, a research professor at the Georgetown University McCourt School of Public Policy's Center for Children and Families.
'You can imagine the state is completely overwhelmed because you have to create and administer a complex system,' Park said.
Supporters of the legislation insist the purpose of the GOP bill is to shore it up for the most vulnerable Americans — the pregnant women, poor children and disabled people it was originally intended to cover.
'If you read the actual language we're working with, it is designed for one major purpose: to allow the president of the United States and the governors who run the states to align on what we should be doing for the most vulnerable members of the population,' Mehmet Oz, who runs the agency that oversees Medicare and Medicaid, said on Politico's 'The Conversation' podcast, which posted Sunday.
Medicaid has become too big, costly and wasteful, said Rep. Brett Guthrie (R-Kentucky), chairman of the House Energy and Commerce Committee, which wrote the Medicaid part of the GOP bill.
'Undoubtedly, Democrats will use this as an opportunity to engage in fear-mongering and misrepresent our bill as an attack on Medicaid,' he wrote in a Wall Street Journal op-ed. 'In reality, it preserves and strengthens Medicaid for children, mothers, people with disabilities and the elderly — for whom the program was designed.'
Republicans swung harder at the Affordable Care Act back in 2017, proposing legislation that was estimated to reduce insurance enrollment by three times as much.
But since that time, enrollment in Medicaid, CHIP and the marketplaces has grown from 86 million Americans to about 100 million, making them even more politically difficult to target. Conservative health policy thinkers — most prominently Brian Blase, whose Medicaid ideas heavily influenced the legislation — say that's precisely why Medicaid needs to be pared back.
Blase, president of Paragon Health Institute, points to the financial realities of transforming Medicaid from a safety net that chiefly covered the most vulnerable into a broader program that in most states now covers people who earn up to $44,000 for a family of four. Medicaid now costs the federal and state governments nearly $900 billion per year, up from about $590 billion in 2017.
On top of that, Blase notes, the federal government has assumed a larger share of Medicaid spending in recent years. That's partly because it covers a much larger share of the costs for Medicaid expansion enrollees compared with people eligible for the program under the old rules.
Additionally, states have been using a loophole that allows them to collect more federal Medicaid dollars. They collect a tax from hospitals and other Medicaid providers which they then pass back in the form of higher state payments, drawing down more federal matching funds.
That maneuver — which Blase and other conservatives term 'money laundering' — is addressed in the GOP bill, which caps state provider taxes and bans states from establishing new ones.
'There has been a massive cost shift from the states to the federal government,' Blase said. 'I think reform needs to put more responsibility back in the states. I think we have a better Medicaid program when states are spending their own money.'
Some Senate Republicans — as they did in 2017 — are balking at the cuts. Chief among them is Sen. Josh Hawley (R-Missouri), who has called them 'morally wrong and politically suicidal.' More than 1 million Missouri residents are on Medicaid. The state expanded the program in 2021.
Republicans who do support the cuts insist they're just going after waste in Medicaid and the marketplaces by kicking ineligible people off the rolls.
'They're looking at fraud, waste and abuse. And nobody minds that,' Trump said on 'Meet the Press' on May 4.
There are no reliable estimates of fraud in Medicaid but reports by the Department of Health and Human Services' inspector general and the Justice Department have indicated that providers like nursing homes, pain clinics and ambulance services — not recipients — are largely the culprits.
Investigators who detect and root out that fraud — Medicaid fraud control units, the HHS inspector general and the DOJ — wouldn't get any new funding under the GOP bill. It does require states to take more steps to ensure no dead people are on the rolls and conduct extra screening of medical providers. But those modest provisions, frequently touted by Republicans, aren't estimated to produce any savings.
Democrats and many health policy experts charge that there's so little fraud in Medicaid and the marketplaces that the coverage losses will mainly be among people who are eligible but fail to jump through all the new hoops created by the GOP legislation.
'They're branding it as eliminating waste, fraud and abuse, which is ridiculous,' said Leslie Dach, who worked on health care in the Obama administration and now heads the Democratic-aligned group Protect Our Care.
Dach and other Democrats are particularly upset about the bill's new work requirements, which produce about one-third of the savings, the biggest chunk. Working-age adults in Medicaid expansion would have to prove to state Medicaid programs at least twice per year that they're either working or volunteering at least 80 hours a month.
Health policy analysts say that would have little effect on labor force participation, because most Medicaid enrollees already work. Eight percent of healthy working-age adults who used Medicaid in 2023 were unemployed and weren't caregiving or attending school, according to KFF, a nonpartisan organization that does health policy research.
Yet work requirements are popular, supported by more than half of Americans and eight in 10 Republicans in a recent KFF poll. That could bode well for Republicans in their effort to sell their bill to the public.
Republicans are also avoiding the deepest pitfall from their 2017 repeal effort: They're not going after the law's popular protections for people with preexisting conditions. The GOP repeal bills had proposed weakening those protections, giving Democrats one of the top lines of attack that helped them win back the House majority the following year.
But to supporters of the Affordable Care Act, the GOP bill is the latest chapter in a story they've watched for years.
'It's death by a thousand cuts,' said Jessica Schubel, who served as a White House adviser on health care during President Joe Biden's administration.