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Yahoo
5 days ago
- Business
- Yahoo
The GOP's 'big, beautiful bill' would leave 10.9 million more uninsured, CBO says
The Republican party's "big, beautiful bill" would leave 10.9 million fewer people in the US with health coverage while cutting more than $1 trillion in spending from federal insurance programs over a decade, the nonpartisan Congressional Budget Office reported on Wednesday. Most of the coverage losses would be due to changes in Medicaid, the health program for low-income, elderly, and disabled children and adults, including new work requirements that are expected to knock millions from its rolls. The rest would be due to reforms to the Affordable Care Act that could make buying insurance through its marketplaces more difficult while also limiting benefits for immigrants. By subscribing, you are agreeing to Yahoo's Terms and Privacy Policy Healthcare experts have described the cuts as unlike any in history and warned that they would undo much of the progress the US has made in reducing the number of people without insurance since the Affordable Care Act passed in 2010. 'This would be the biggest rollback in federal support for healthcare ever,' Larry Levitt, executive vice president for health policy at the think tank KFF said on X. The new numbers are similar to previous estimates from Capitol Hill, but they were updated to reflect the final version of the legislation passed by the House of Representatives last month and to show how different portions of the bill would interact with each other. According to the CBO, the GOP's legislation would reduce Medicaid enrollment by about 7.8 million. Much of the drop would be due to new rules requiring that able-bodied, childless adults spend at least 80 hours a month at work, in community service, or in an education program. The change is expected to shave $344 billion from the program, out of about $780 billion in total cuts. The White House has tried to cast doubt on the CBO's numbers, suggesting with little evidence that its staff may be politically biased. Other Republicans have argued that the office's estimates are simply overblown and that the work rules are a 'common sense' reform that won't reduce coverage for individuals who truly need it. 'You're telling me that you're going to require the able-bodied, these young men, for example, to only work or volunteer in their community for 20 hours a week. And that's too cumbersome for them?" House Speaker Mike Johnson said on this Sunday's "Meet the Press." "I'm not buying it. The American people are not buying it." But other healthcare experts have argued that work requirements are likely to block many Americans from coverage they are legally eligible for simply by piling on paperwork and red tape. They point to Arkansas' brief attempt to impose work rules during the first Trump administration, which led to about 18,000 residents losing coverage even though 'nearly everyone who was targeted by the policy already met the requirements,' as one study found. Many of the bill's changes to the Affordable Care Act are more technical, but together they would narrow the opportunities for individuals to sign up and stay enrolled. They include shortening the open enrollment period and ending the ability of lower-income adults to buy coverage throughout the year. Customers will also no longer be able to automatically reenroll in their health plan from year to year, thanks to new requirements that they annually verify their income and residency. Conservatives have argued that the changes are necessary to prevent fraudulent enrollments on the insurance exchanges, but more left-leaning experts have argued that the bill is simply trying to cut spending by throwing up unnecessary roadblocks. 'What they've done in both the marketplaces and Medicaid is that they've made it much harder to get and maintain your coverage,' said Sara Collins, vice president for healthcare coverage and access at the Commonwealth Fund. Republicans have emphasized that some of their reforms are intended to cut coverage to illegal immigrants. For instance, the bill would ban states from using their own money to extend Medicaid coverage to undocumented residents, which the CBO estimates will lead to about 1.4 million more people uninsured. The majority of coverage losses would fall on American citizens and legal residents, however, with 9.5 million more uninsured. Separately from the GOP bill, the number of Americans without insurance is expected to increase significantly after next year when expanded Obamacare subsidies passed under the Biden Administration are set to expire, significantly increasing premiums. The CBO has forecast that about 4.2 million fewer people will have coverage as a result. Between those losses, the One Big Beautiful Bill Act, and regulatory changes the Trump administration has proposed, the office has projected that about 16 million fewer Americans will be insured over the coming decade. Matthew Fiedler, a healthcare expert at the Brookings Institution, estimates that the US uninsured rate will increase to about 12 percent from around 7.7 percent today — undoing about half the decline since the Affordable Care Act was passed in 2010. 'We're on track for a fairly unprecedented increase in the uninsured rate,' he said. Jordan Weissmann is a Senior Reporter at Yahoo Finance. Sign up for the Mind Your Money newsletter
Yahoo
22-05-2025
- Business
- Yahoo
There's a reason Republicans want to hide what's in their megabill
Early Wednesday, when most Americans were snuggled in their beds, Republicans in the House of Representatives were working hard to take away the health care of millions of Americans, blow a $3 trillion hole in the budget deficit and make the wealthiest people in America richer and the poorest Americans poorer. If this sounds like hyperbole, it's not. The GOP-controlled House Rules Committee convened at 1 a.m. Wednesday morning to discuss a bill that hasn't been fully drafted and the provisions of which were still part of intense negotiations. Indeed, the real work on the legislation was happening behind closed doors as House Speaker Mike Johnson, R-La., tried to cobble together enough votes to pass something, anything, so he could meet his self-imposed deadline for a floor vote by Memorial Day. Late Wednesday, GOP leaders released yet more significant changes to the bill, and on Thursday morning the full House passed the bill by a single vote. What we do know about the legislation the GOP is calling the 'One Big Beautiful Bill Act' is genuinely terrifying. According to an analysis published Tuesday by the Congressional Budget Office, the numbers in the GOP's draft legislation are brutal. The bill would increase the federal deficit by $3.8 trillion — a rise that is spooking bond markets already worried about the president's tariff increases. The bill would slash $267 billion in federal spending for SNAP, which more than 42 million low-income people rely on to put food on the table for their families. And it would cut nearly $700 billion from federal funding for Medicaid. The CBO estimated Tuesday that the Medicaid cuts could cause roughly 8 million people to lose their health insurance coverage, and that number could rise to 15 million thanks to other provisions in the legislation. The amendments revealed Wednesday, writes Larry Levitt, executive vice president for health policy at KFF, surely 'would lead to more people losing health insurance.' But Republicans scrambled to vote Thursday before the CBO could update its totals. All this is being done to extend the Trump tax cuts, which disproportionately benefit wealthy people. The impact of the GOP's bill is extraordinary in both its cruelty and its extreme inequality. According to the CBO's estimate, household resources for the poorest people would decrease by 4% over the next eight years, while the richest people's household resources would increase by 4%. If enacted, the bill would constitute the largest transfer of wealth from the needy to the wealthy in American history. It's no wonder, then, that Republicans were rushing this bill through while most Americans slept. If you were robbing the poor on behalf of the rich, you, too, would do it in the dead of night. This obfuscation has become par for the course as this legislation has wound its way through Congress. As Bulwark's Jonathon Cohn pointed out last week, the House Energy and Commerce Committee, which is responsible for overseeing Medicaid, hasn't held a single hearing to examine the implications of these changes to the American health care system. Instead, it merely held a markup hearing to move the legislation closer to a vote on the House floor. What makes this situation even worse is that Republicans, from the president on down, are consistently lying about what the bill would do. Earlier this week, White House press secretary Karoline Leavitt claimed that this bill, which would blow a $3 trillion hole in the federal budget, wouldn't increase the deficit. Leavitt even claimed that there are '$1.6 trillion worth of savings in this bill' and that this number represents 'the largest savings for any legislation that has ever passed Capitol Hill in our nation's history.' (Leavitt provided no source for this figure, and it appears she simply referred to the spending cuts in the bill while ignoring the trillions in lost revenue that will come from the tax cuts.) It is as stunning a lie as perhaps any other uttered by members of the Trump administration (and that is saying something). Even one House Republican, Thomas Massie of Kentucky, is publicly calling the White House and his colleagues liars for promoting this fiction. On Tuesday, President Donald Trump traveled to Capitol Hill to lobby Republicans and told reporters that Republicans are 'not doing any cutting of anything meaningful. The only thing we're cutting is waste, fraud and abuse.' This, too, is a bald-faced lie. House Republicans have consistently claimed that the bill's work requirements for Medicaid recipients are meant to get the 'able-bodied' into the workplace. Such people, according to the No. 2 Republican in the House, Steve Scalise of Louisiana, are 'living in their mom's basement playing video games.' In fact, nearly two-thirds of those on Medicaid are already working. Almost all other recipients aren't working because of caregiving, school, illness or disability. In states where work requirements have been imposed on Medicaid recipients, the result is a drop in coverage, which almost certainly is the reason Republicans are including them in their big, beautiful bill. The fewer people on Medicaid, the greater the cost savings, and the more money there is for tax breaks. Indeed, what is happening on Capitol Hill can hardly be described as legislating. Making laws means hearing from experts, considering data and weighing pros and cons. The GOP's 'Big, Beautiful Bill' is none of those things. It's highway robbery, and Republicans desperately don't want the American people to know that they are the ones holding them up. This article was originally published on
Yahoo
21-04-2025
- Health
- Yahoo
Supreme Court hears challenge to Obamacare no-cost preventive health benefits
Preventive care health benefits provided at no cost to tens of millions of Americans since 2010 under a popular provision of the Affordable Care Act are in the balance Monday at the U.S. Supreme Court as the justices consider whether the government task force behind the mandate to insurers is unconstitutional. Among the services the U.S. Preventive Services Task Force designates for no-cost coverage under the federal health law are statins to lower cholesterol; colonoscopies for 45- to 49-year-olds; preexposure prophylaxis (PrEP) medicine to reduce the spread of HIV; medications to lower the risk of breast cancer for women; and lung cancer screenings for smokers. The case was brought by a group of employers and individuals who oppose some of the task force's recommendations for covered services on religious groups, specifically the PrEP medication to prevent HIV. They allege the group's structure violates the Constitution and lower federal courts agreed. MORE: Supreme Court to hear arguments over injunctions on Trump bid to end birthright citizenship If the justices uphold the decisions, the task force and its recommendations since 2010 could be invalidated -- and along with them the guarantee of no-cost preventive services coverage many people enjoy. "The case is not the kind of existential threat that we have seen in previous Supreme Court cases involving the ACA, but it's certainly something that could affect a lot of people," said Larry Levitt, executive vice president at KFF, a nonpartisan health policy group. At the heart of the dispute is whether the structure of the 16-member task force is illegal under the Constitution's Appointments Clause. The provision requires "principle officers" of the U.S. government, such as Cabinet secretaries and ambassadors, to be confirmed by the Senate. It stipulates that "inferior officers" who are appointed by Senate-confirmed officials are permissible, provided they are supervised and reviewed. The plaintiffs allege that members of the task force, who are appointed and supervised by the Health and Human Services secretary, are not properly appointed and have too much power. While they can be removed at will, their recommendations for covered health services cannot be reviewed or overridden by anyone. 'Americans have the constitutionally protected freedom to live and work according to their religious beliefs, and governments exist to defend that freedom," said Daniel Grabowski, an attorney with Alliance Defending Freedom, a conservative legal advocacy group supporting the plaintiffs. "We urge the Supreme Court to restore this accountability within the federal government and to the American people.' The Fifth Circuit U.S. Court of Appeals ruled the task force unconstitutional and that its recommendations since 2010 be invalidated. The Trump administration is defending the constitutionality of the task force and the health secretary's power to oversee the body's recommendations. More than 150 million Americans rely on early screenings and interventions for chronic conditions under no-cost preventive services, according to American medical organizations. Public health groups say a decision striking down the task force could deeply affect the long-term health of Americans and disease prevention efforts. Insurers worry that it could inject instability into the insurance market, while hospital groups fear they may have to shoulder more of the burden from people who are sicker. MORE: Supreme Court tepid on Trump while defending power to check president: ANALYSIS "The ACA's preventive services requirement has been a game-changer, providing access to evidence-based preventive care and early detection of serious medical conditions," said Wayne Turner, a senior attorney at the National Health Law Program, a nonprofit group that advocates for low-income communities. "The ACA's coverage and cost-sharing protections are especially important for low-income persons, who will be harmed most if the Supreme Court refuses to allow the ACA provision to stand." Oral arguments in the case -- Kennedy v. Braidwood Management -- will be heard at the Supreme Court on Monday. A decision in the case is expected by the end of June. Supreme Court hears challenge to Obamacare no-cost preventive health benefits originally appeared on
CNN
20-04-2025
- Business
- CNN
Analysis: Republicans are targeting a pillar of Obamacare. Millions of their own voters may pay a price
As the pressure grows on congressional Republicans to identify cuts in Medicaid, they are crashing into a familiar problem: The changes that could save the most money would impose heavy costs on many of their own voters. Several key House Republicans have signaled in recent days that they may try to cut Medicaid spending by rolling back the expansion in eligibility for the working poor included in the Affordable Care Act approved under President Barack Obama. That option may be attractive to Republicans partly because the states that have most aggressively used that authority to expand eligibility mostly lean Democratic. Most House districts where more people than the national average receive health coverage through the Medicaid expansion are also held by Democrats, according to an exclusive new CNN analysis of data from KFF, a non-partisan health care think tank. But GOP constituencies would hardly be immune if Congress rescinds the expansion. Nearly three dozen House Republicans also represent districts where the number of people receiving coverage through that Medicaid expansion exceeds the national district average of about 61,600, the analysis found. And nearly two dozen GOP senators likewise represent states with a substantial population of enrollees covered through the ACA's Medicaid expansion. 'It's really a similar pattern that we've seen with the Affordable Care Act generally – that it's become so embedded in the health care system and the lives of people across the country that it becomes very hard to take it away,' said Larry Levitt, executive vice president for health policy at KFF. Answers on whether the expansion is too entrenched for congressional Republicans to uproot could begin arriving as soon as May 7, when the House Energy and Commerce Committee, which holds jurisdiction over Medicaid, is expected to start marking up the GOP's massive budget 'reconciliation' plan. For all the controversy around both President Donald Trump's assaults on civil liberties and his tariff moves, it's likely that the most politically consequential decision congressional Republicans face this year is how to balance spending and tax cuts in the budget package they are formulating. With Trump ruling out cuts in Social Security or Medicare benefits, Medicaid represents by far the largest pot of money available for the reductions that conservative budget hawks are demanding. The House budget resolution has instructed the Energy and Commerce Committee to find $880 billion in savings over the next decade; the Congressional Budget Office recently calculated that even if the committee completely zeroed out the other programs in its purview, it still could not reach that number without cutting Medicaid. Republicans have long viewed Medicaid, which now provides health coverage for about 83 million lower-income Americans, as a more vulnerable target than Medicare, which serves seniors; GOP attempts to cut Medicaid and convert it into a block grant were central to the 1990s budget showdowns between President Bill Clinton and then-House Speaker Newt Gingrich. The bill House Republicans passed in 2017 to repeal the Affordable Care Act included major cutbacks in Medicaid, including a variation on the Gingrich-era block grant proposal. But both the Medicaid population and the GOP electoral coalition have evolved in ways that complicate the party's choices. The ACA expanded eligibility for Medicaid to far more working poor people. Previously, single childless adults were not eligible for the program at any income level; the ACA allowed states to cover those making up to 138% of the federal poverty level ($15,650 for an individual and about $21,000 for a married couple in 2025). The ACA also allowed states to raise the eligibility level for parents of young children to 138% of the poverty level; many states, particularly in the South, had cut off eligibility for parents at far lower levels before. To encourage states to broaden coverage, the ACA committed Washington to funding 90% of the cost of the expansion population, much more than it pays states for other people covered through Medicaid (generally one-half to three-quarters, depending on the state). All but 10 states have now expanded Medicaid eligibility under the ACA, covering more than 20 million people in all. Even as the ACA expanded Medicaid eligibility up the income ladder to more working poor families, Republicans extended their electoral reach down the income and educational ladder through the political realignment accelerated under Trump. The result, as I wrote recently with CNN senior producer Edward Wu, is that 64 House Republicans now represent districts in which the share of Medicaid recipients exceeds the average for all districts. Far more Republicans than Democrats also represent districts with greater than average prevalence of major health problems including diabetes, obesity and high blood pressure – a reflection of the GOP's growing consolidation of lower-education, lower-income, often rural House districts. These shifts clearly have made congressional Republicans more uneasy about cutting Medicaid than in the 1990s, or even in 2017. But the Medicaid expansion population has remained a tempting target for them. For one thing, the expansion is tied to the ACA, or Obamacare, which many Republicans, from Trump on down, still disparage. The expansion population, which includes people above the poverty line, is also more susceptible to the traditional argument Republicans have wielded against social welfare programs: that they reward the 'undeserving poor' who should be paying their own way. In recent weeks, multiple House Republicans have subtly, but tellingly, distinguished between Medicaid's traditional enrollees – very low-income parents, people with disabilities, impoverished seniors – and those added under the ACA expansion. House Speaker Mike Johnson has repeatedly called for revoking Medicaid eligibility for 'able-bodied workers, for example, young men … who should never be on the program at all.' Even a dozen House Republicans from swing districts who wrote Johnson last week expressing caution about Medicaid reductions made a similar distinction: while they would oppose cuts hurting 'vulnerable populations,' they also said they want to 'fix flaws in the program that divert resources away from children, seniors, individuals with disabilities, and pregnant women — those who the program was intended to help.' (Emphasis added.) The most specific proposal for reversing the Medicaid expansion has come from Paragon Health Institute, a conservative health care think tank. Paragon has proposed to phase out the enhanced federal assistance for the expansion population over a decade, reducing it to the same reimbursement Washington offers for other recipients. 'We're 15 years post the ACA and I think the question for policy makers is: under what rationale should we paying more for childless adults than kids, pregnant women and people with disabilities on the program?' Brian Blase, the institute's president and a health policy adviser to Trump during his first term, said in a recent interview. Paragon projects that about 3 million people would lose health care coverage from the shift. That's largely because it anticipates that most of those removed from Medicaid would qualify for federal subsidies to buy private health insurance through the ACA marketplaces. But the Urban Institute, a center-left think tank, has projected that nearly 11 million people would lose health coverage if Congress revokes the enhanced Medicaid funding for the working poor. If states tried to maintain the current eligibility levels with their own funds, the Urban Institute found, it would require them to increase their Medicaid spending by about 25% annually, a virtual impossibility. Meanwhile, it would become much harder for people kicked off Medicaid to obtain coverage instead through the Obamacare exchanges if Republicans allow the enhanced ACA subsidies approved under President Joe Biden to expire this year, as they have signaled is likely. 'If people in the expansion population lose coverage, they may be eligible on paper for the marketplace but many of them would not be able to afford it,' especially if the enhanced subsidies expire, said Allison Orris, director of Medicaid policy at the Center on Budget and Policy Priorities, a liberal group. The new analysis of the KFF data by Wu, the senior CNN producer, suggests Republicans are right in their instinct that ending the expansion would rattle more windows in Democratic than GOP-leaning areas. Ninety-eight Democrats represent districts where more people than the average are covered through the expansion, the analysis found. So many congressional Democrats represent big expansion populations , largely because the states that have added the most people through the expansion tend to be places where Democrats are highly competitive, including blue states California, New York, Illinois, Oregon and Virginia, as well as purple battlegrounds like Pennsylvania, Michigan, and Arizona, which are all in the top 10. Democrats, in fact, hold 46 more House seats than Republicans in the states that have expanded Medicaid eligibility, Wu calculated. Conversely, Republicans in Congress are less exposed, largely because the 10 states that have refused to expand Medicaid – headlined by Texas, Florida and Georgia – all lean red, with the exception of Wisconsin (where the GOP-controlled legislature has long blocked expansion). Nearly 40% of House Republicans represent just those 10 states. Even so, the number of House Republicans from expansion states with large numbers of residents – and health care providers – who have come to rely on the new coverage still far exceeds the number of defections that would sink any budget plan. Thirty-two House Republicans also hold seats with an above-average number of expansion beneficiaries; 14 of them represent districts with 80,000 or more Medicaid expansion enrollees. And while the total number of expansion enrollees is greatest in Democratic-held districts (about 12.6 million), the 6.8 million in GOP seats still constitute a very large number of potential voters. Likewise, 22 Republican senators have been elected from the 29 states that have covered at least 100,000 people under the expansion, according to the KFF data. Another factor could make Republicans hesitate about unwinding the expansion: its importance to health care systems in reliably red rural areas. In an interview, North Carolina Medicaid Director Jay Ludlam , for instance, pointed out that rural residents make up twice as big a share of the state's Medicaid expansion population as they do of the overall population. Experts say that dynamic, which is evident in other states too, is primarily because workers in rural places are less likely to receive health insurance from their employers. Through the expansion, Ludlam said, 'We have seen individuals get medicines for heart disease, diabetes, for treatment of seizures – chronic diseases that would go otherwise untreated.' If people lose that coverage, he continued, 'initially what you would start to see is an uptick in emergency room visits, which is an incredibly expensive way to provide health care,' with 'eventually some of those chronic diseases beginning to have a really adverse impact on the health of many people.' The best example of how all these pressures converge may be Speaker Johnson's own state of Louisiana. As a lower-income, heavily rural state, Louisiana has been among the greatest beneficiaries of the Medicaid expansion. The state expanded eligibility under Democratic Gov. John Bel Edwards in 2016 and his Republican successor, Gov. Jeff Landry, has not sought to repeal it. According to Kaiser, Louisiana has signed up nearly 800,000 people for the expansion, more than all but four other (and much larger) states. Johnson and fellow Louisiana GOP Reps. Julia Letlow, Clay Higgins and Steve Scalise each have more than 100,000 district residents receiving Medicaid through the expansion, which places all of them among the top eight of all House Republicans. Jan Moller, executive director of Invest in Louisiana, an advocacy group for low-income families, says the Medicaid expansion has also provided a financial lifeline for the state's health care providers. While rural hospitals are struggling in many states, he notes, none have closed in Louisiana since the expansion. 'If you drive around Louisiana,' he added, 'you will see a lot of clinics … where they didn't exist 10 to 15 years ago.' Revoking expansion funding, Moller said, 'would be devastating for Louisiana's budget, and it would seriously threaten health care access for the 1 in 3 Lousianians who depend on Medicaid.' Even people with private insurance or Medicare would be hurt, Moller added, if reduced Medicaid revenue forces hospitals and other providers to close, particularly in rural areas with fewer alternatives. That could be a common problem in many states, Orris said. 'Pulling as much money out of the health care system as they are talking about … will hurt everyone in a community,' she said. If congressional Republicans can't find the votes to directly reverse the expansion, they have signaled they may seek to truncate it by imposing a work requirement on Medicaid recipients. (Missouri GOP Sen. Josh Hawley, for instance, has said he will not support cuts in benefits, but would back a work requirement.) Surveys have found about two-thirds of people on Medicaid already work full- or part-time, and almost all the rest would likely be exempt from any mandate because of factors such as a disability or caring for a family member. But when Arkansas and New Hampshire experimented with work requirements in Trump's first term, large numbers of people were still thrown off the program for failing to meet the paperwork requirements to document their work. The same could happen with a federal mandate. It would be a bitter irony if a work requirement becomes a vehicle to erase the Medicaid expansion's historic gains in extending health coverage to the working poor – in red places as well as blue.
CNN
20-04-2025
- Business
- CNN
Analysis: Republicans are targeting a pillar of Obamacare. Millions of their own voters may pay a price
As the pressure grows on congressional Republicans to identify cuts in Medicaid, they are crashing into a familiar problem: The changes that could save the most money would impose heavy costs on many of their own voters. Several key House Republicans have signaled in recent days that they may try to cut Medicaid spending by rolling back the expansion in eligibility for the working poor included in the Affordable Care Act approved under President Barack Obama. That option may be attractive to Republicans partly because the states that have most aggressively used that authority to expand eligibility mostly lean Democratic. Most House districts where more people than the national average receive health coverage through the Medicaid expansion are also held by Democrats, according to an exclusive new CNN analysis of data from KFF, a non-partisan health care think tank. But GOP constituencies would hardly be immune if Congress rescinds the expansion. Nearly three dozen House Republicans also represent districts where the number of people receiving coverage through that Medicaid expansion exceeds the national district average of about 61,600, the analysis found. And nearly two dozen GOP senators likewise represent states with a substantial population of enrollees covered through the ACA's Medicaid expansion. 'It's really a similar pattern that we've seen with the Affordable Care Act generally – that it's become so embedded in the health care system and the lives of people across the country that it becomes very hard to take it away,' said Larry Levitt, executive vice president for health policy at KFF. Answers on whether the expansion is too entrenched for congressional Republicans to uproot could begin arriving as soon as May 7, when the House Energy and Commerce Committee, which holds jurisdiction over Medicaid, is expected to start marking up the GOP's massive budget 'reconciliation' plan. For all the controversy around both President Donald Trump's assaults on civil liberties and his tariff moves, it's likely that the most politically consequential decision congressional Republicans face this year is how to balance spending and tax cuts in the budget package they are formulating. With Trump ruling out cuts in Social Security or Medicare benefits, Medicaid represents by far the largest pot of money available for the reductions that conservative budget hawks are demanding. The House budget resolution has instructed the Energy and Commerce Committee to find $880 billion in savings over the next decade; the Congressional Budget Office recently calculated that even if the committee completely zeroed out the other programs in its purview, it still could not reach that number without cutting Medicaid. Republicans have long viewed Medicaid, which now provides health coverage for about 83 million lower-income Americans, as a more vulnerable target than Medicare, which serves seniors; GOP attempts to cut Medicaid and convert it into a block grant were central to the 1990s budget showdowns between President Bill Clinton and then-House Speaker Newt Gingrich. The bill House Republicans passed in 2017 to repeal the Affordable Care Act included major cutbacks in Medicaid, including a variation on the Gingrich-era block grant proposal. But both the Medicaid population and the GOP electoral coalition have evolved in ways that complicate the party's choices. The ACA expanded eligibility for Medicaid to far more working poor people. Previously, single childless adults were not eligible for the program at any income level; the ACA allowed states to cover those making up to 138% of the federal poverty level ($15,650 for an individual and about $21,000 for a married couple in 2025). The ACA also allowed states to raise the eligibility level for parents of young children to 138% of the poverty level; many states, particularly in the South, had cut off eligibility for parents at far lower levels before. To encourage states to broaden coverage, the ACA committed Washington to funding 90% of the cost of the expansion population, much more than it pays states for other people covered through Medicaid (generally one-half to three-quarters, depending on the state). All but 10 states have now expanded Medicaid eligibility under the ACA, covering more than 20 million people in all. Even as the ACA expanded Medicaid eligibility up the income ladder to more working poor families, Republicans extended their electoral reach down the income and educational ladder through the political realignment accelerated under Trump. The result, as I wrote recently with CNN senior producer Edward Wu, is that 64 House Republicans now represent districts in which the share of Medicaid recipients exceeds the average for all districts. Far more Republicans than Democrats also represent districts with greater than average prevalence of major health problems including diabetes, obesity and high blood pressure – a reflection of the GOP's growing consolidation of lower-education, lower-income, often rural House districts. These shifts clearly have made congressional Republicans more uneasy about cutting Medicaid than in the 1990s, or even in 2017. But the Medicaid expansion population has remained a tempting target for them. For one thing, the expansion is tied to the ACA, or Obamacare, which many Republicans, from Trump on down, still disparage. The expansion population, which includes people above the poverty line, is also more susceptible to the traditional argument Republicans have wielded against social welfare programs: that they reward the 'undeserving poor' who should be paying their own way. In recent weeks, multiple House Republicans have subtly, but tellingly, distinguished between Medicaid's traditional enrollees – very low-income parents, people with disabilities, impoverished seniors – and those added under the ACA expansion. House Speaker Mike Johnson has repeatedly called for revoking Medicaid eligibility for 'able-bodied workers, for example, young men … who should never be on the program at all.' Even a dozen House Republicans from swing districts who wrote Johnson last week expressing caution about Medicaid reductions made a similar distinction: while they would oppose cuts hurting 'vulnerable populations,' they also said they want to 'fix flaws in the program that divert resources away from children, seniors, individuals with disabilities, and pregnant women — those who the program was intended to help.' (Emphasis added.) The most specific proposal for reversing the Medicaid expansion has come from Paragon Health Institute, a conservative health care think tank. Paragon has proposed to phase out the enhanced federal assistance for the expansion population over a decade, reducing it to the same reimbursement Washington offers for other recipients. 'We're 15 years post the ACA and I think the question for policy makers is: under what rationale should we paying more for childless adults than kids, pregnant women and people with disabilities on the program?' Brian Blase, the institute's president and a health policy adviser to Trump during his first term, said in a recent interview. Paragon projects that about 3 million people would lose health care coverage from the shift. That's largely because it anticipates that most of those removed from Medicaid would qualify for federal subsidies to buy private health insurance through the ACA marketplaces. But the Urban Institute, a center-left think tank, has projected that nearly 11 million people would lose health coverage if Congress revokes the enhanced Medicaid funding for the working poor. If states tried to maintain the current eligibility levels with their own funds, the Urban Institute found, it would require them to increase their Medicaid spending by about 25% annually, a virtual impossibility. Meanwhile, it would become much harder for people kicked off Medicaid to obtain coverage instead through the Obamacare exchanges if Republicans allow the enhanced ACA subsidies approved under President Joe Biden to expire this year, as they have signaled is likely. 'If people in the expansion population lose coverage, they may be eligible on paper for the marketplace but many of them would not be able to afford it,' especially if the enhanced subsidies expire, said Allison Orris, director of Medicaid policy at the Center on Budget and Policy Priorities, a liberal group. The new analysis of the KFF data by Wu, the senior CNN producer, suggests Republicans are right in their instinct that ending the expansion would rattle more windows in Democratic than GOP-leaning areas. Ninety-eight Democrats represent districts where more people than the average are covered through the expansion, the analysis found. So many congressional Democrats represent big expansion populations , largely because the states that have added the most people through the expansion tend to be places where Democrats are highly competitive, including blue states California, New York, Illinois, Oregon and Virginia, as well as purple battlegrounds like Pennsylvania, Michigan, and Arizona, which are all in the top 10. Democrats, in fact, hold 46 more House seats than Republicans in the states that have expanded Medicaid eligibility, Wu calculated. Conversely, Republicans in Congress are less exposed, largely because the 10 states that have refused to expand Medicaid – headlined by Texas, Florida and Georgia – all lean red, with the exception of Wisconsin (where the GOP-controlled legislature has long blocked expansion). Nearly 40% of House Republicans represent just those 10 states. Even so, the number of House Republicans from expansion states with large numbers of residents – and health care providers – who have come to rely on the new coverage still far exceeds the number of defections that would sink any budget plan. Thirty-two House Republicans also hold seats with an above-average number of expansion beneficiaries; 14 of them represent districts with 80,000 or more Medicaid expansion enrollees. And while the total number of expansion enrollees is greatest in Democratic-held districts (about 12.6 million), the 6.8 million in GOP seats still constitute a very large number of potential voters. Likewise, 22 Republican senators have been elected from the 29 states that have covered at least 100,000 people under the expansion, according to the KFF data. Another factor could make Republicans hesitate about unwinding the expansion: its importance to health care systems in reliably red rural areas. In an interview, North Carolina Medicaid Director Jay Ludlam , for instance, pointed out that rural residents make up twice as big a share of the state's Medicaid expansion population as they do of the overall population. Experts say that dynamic, which is evident in other states too, is primarily because workers in rural places are less likely to receive health insurance from their employers. Through the expansion, Ludlam said, 'We have seen individuals get medicines for heart disease, diabetes, for treatment of seizures – chronic diseases that would go otherwise untreated.' If people lose that coverage, he continued, 'initially what you would start to see is an uptick in emergency room visits, which is an incredibly expensive way to provide health care,' with 'eventually some of those chronic diseases beginning to have a really adverse impact on the health of many people.' The best example of how all these pressures converge may be Speaker Johnson's own state of Louisiana. As a lower-income, heavily rural state, Louisiana has been among the greatest beneficiaries of the Medicaid expansion. The state expanded eligibility under Democratic Gov. John Bel Edwards in 2016 and his Republican successor, Gov. Jeff Landry, has not sought to repeal it. According to Kaiser, Louisiana has signed up nearly 800,000 people for the expansion, more than all but four other (and much larger) states. Johnson and fellow Louisiana GOP Reps. Julia Letlow, Clay Higgins and Steve Scalise each have more than 100,000 district residents receiving Medicaid through the expansion, which places all of them among the top eight of all House Republicans. Jan Moller, executive director of Invest in Louisiana, an advocacy group for low-income families, says the Medicaid expansion has also provided a financial lifeline for the state's health care providers. While rural hospitals are struggling in many states, he notes, none have closed in Louisiana since the expansion. 'If you drive around Louisiana,' he added, 'you will see a lot of clinics … where they didn't exist 10 to 15 years ago.' Revoking expansion funding, Moller said, 'would be devastating for Louisiana's budget, and it would seriously threaten health care access for the 1 in 3 Lousianians who depend on Medicaid.' Even people with private insurance or Medicare would be hurt, Moller added, if reduced Medicaid revenue forces hospitals and other providers to close, particularly in rural areas with fewer alternatives. That could be a common problem in many states, Orris said. 'Pulling as much money out of the health care system as they are talking about … will hurt everyone in a community,' she said. If congressional Republicans can't find the votes to directly reverse the expansion, they have signaled they may seek to truncate it by imposing a work requirement on Medicaid recipients. (Missouri GOP Sen. Josh Hawley, for instance, has said he will not support cuts in benefits, but would back a work requirement.) Surveys have found about two-thirds of people on Medicaid already work full- or part-time, and almost all the rest would likely be exempt from any mandate because of factors such as a disability or caring for a family member. But when Arkansas and New Hampshire experimented with work requirements in Trump's first term, large numbers of people were still thrown off the program for failing to meet the paperwork requirements to document their work. The same could happen with a federal mandate. It would be a bitter irony if a work requirement becomes a vehicle to erase the Medicaid expansion's historic gains in extending health coverage to the working poor – in red places as well as blue.
