It’s undeniable: The House Republican reconciliation bill would take health coverage away from millions of people to partially pay for trillions in tax cuts, which are skewed to wealthy people and corporations. But the legislation’s backers would rather dismiss these uncomfortable facts and the people harmed by the bill they support.
“No one will lose coverage a result” of this bill, Office of Management and Budget Director Russ Vought recently said. “People will not lose their Medicaid unless they choose to do so,” House Speaker Mike Johnson claimed.
These comments ignore the unprecedented harm the House legislation would inflict. Republicans’ proposed cuts — and their decision to let tax credits for the Affordable Care Act marketplaces expire — would cause an estimated 16 million people to become uninsured by 2034.
Taking away people’s coverage doesn’t make them healthier or help them find a job.
Many of the House bill’s cuts target people enrolled through the ACA’s Medicaid expansion for low-income adults, which most states adopted and without which many of these adults would lack any pathway to coverage. Johnson’s contention that only Americans who “choose” to will lose coverage refers to the bill’s so-called work requirements. But there’s little choice — for individuals or states — under those harsh provisions, which take coverage away from certain low-income adults when they can’t prove in a red-tape-laden process that they are working or should be exempt.
In fact, more than 90% of adults on Medicaid either work full time or part time or meet exemptions like disability, education or caregiving. Most of the remainder are retired or unable to find work. Under the GOP bill, the Congressional Budget Office estimates 5.2 million adults would lose Medicaid because of the work requirement, and other analysts, including my colleagues at the Center on Budget and Policy Priorities, think the number could be higher.
Also, under this bill, people would have to be employed to get Medicaid coverage in the first place. This harms people who lose employer coverage after a layoff, or who get sick and need care to get better and find work.
Taking away people’s coverage doesn’t make them healthier or help them find a job. The work requirements’ main function is to reduce federal investment in health care by leaving more people uninsured; it is the single biggest Medicaid cut in the House bill.
The bill wouldn’t just hurt people with Medicaid, but those with plans through the Affordable Care Act marketplaces. During Joe Biden’s presidency, Democrats in Congress passed enhanced subsidies that have greatly lowered the costs of plans on the ACA’s marketplaces. But those tax credits expire at the end of the year, and Republicans in Congress also haven’t extended them. That will mean premiums will spike and, the Congressional Budget Office estimates, 4.2 million people will become uninsured.
The GOP bill goes out of its way to make it harder for all Medicaid and marketplace plan enrollees to get and keep coverage.
Worse, millions who manage to stay covered will still face higher health care costs, even as families are already struggling with rising costs for food, rent and other household expenses. The ACA marketplaces, meanwhile, are a critical source of coverage for people who lack employer coverage, such as gig workers, low-paid workers and older people not yet eligible for Medicare.
In total, by letting the ACA marketplace subsidies expire, the House bill would cause health coverage costs to skyrocket for about 22 million people, including 3 million small-business owners and self-employed workers. A typical family of four with income of $65,000 would pay $2,400 more per year to keep their marketplace coverage.
The GOP bill goes out of its way to make it harder for all Medicaid and marketplace plan enrollees to get and keep coverage. Republicans would impose a set of overlapping, punitive policies designed to trip up people, such as more frequent eligibility checks for some and shorter enrollment periods. And speaking of punitive policies, the House bill blocks access to coverage for millions of people who are immigrants. It strips many people lawfully present in the U.S. of their ability to buy affordable ACA marketplace plans and of their access to Medicare benefits. It even penalizes states that provide comprehensive health coverage under Medicaid to certain immigrants with their own funds. Republicans claim the cuts target people without documented immigration status, but those people already do not qualify for Medicaid, Medicare or financial help under the ACA. The cuts would hurt immigrants who lawfully live and work in the U.S., including refugees, people granted asylum, and victims of domestic violence and labor or sex trafficking. Losing coverage means losing access to lifesaving treatments for costly illnesses like cancer and chronic diseases like diabetes. People with disabilities, older adults, children and the many people in low-paid jobs that lack health benefits will delay or avoid needed care, and more people will contend with bankruptcy and medical debt. Finally, the House bill doesn’t just threaten access to care for all Medicaid enrollees, but for entire communities as well. Provider payments would likely drop in all states, which would struggle to keep local providers whole as they grapple with increases in uncompensated care. To take one example, Medicaid covers nearly half of all births in rural hospitals. These hospitals are already more likely to experience negative operating margins and can ill afford massive Medicaid cuts. Rural hospital closures will risk people’s lives as labor and delivery services, emergency services, or other lifesaving measures become out of reach. No matter what GOP lawmakers and officials like Johnson and Vought say, you can’t strip hundreds of billions of dollars out of Medicaid and the ACA and claim with a straight face that no one will lose coverage. And whether people have access to health care or not, their health care needs won’t go away. Thankfully, the House bill isn’t law yet. The Senate still has time to reject provisions that leave millions of people uninsured, raise costs for millions more, and upend the major programs that provide low-income people with lifesaving health care around the country.
Sarah Lueck
Sarah Lueck is the vice president for health policy at the Center for Budget and Policy Priorities. 
