The Senate version of President Donald Trump’s extensive tax and immigration spending plan threatens to reverse significant progress made under the Affordable Care Act (ACA). According to nonpartisan estimates, this legislation could lead to at least 17 million Americans losing their health coverage. The bill, which narrowly passed in the Senate and is now set for a vote in the House, aims to dismantle key components of the ACA—President Barack Obama’s landmark initiative that significantly increased health insurance access for millions of Americans.
The Congressional Budget Office (CBO) estimates that the Senate's version of the bill would result in an additional 11.8 million uninsured individuals by 2034, largely due to cuts to Medicaid. This figure contrasts with an estimated 10.9 million who would remain uninsured if the House version of the bill were enacted. Both proposals include provisions that would end pandemic-era enhanced subsidies for health insurance through ACA marketplaces by year-end, leading to a sharp increase in out-of-pocket expenses for millions of Americans. The CBO indicates that this change alone could result in an additional 4.2 million people losing their insurance.
Moreover, both versions of the bill contain provisions that could hinder states' ability to maintain the ACA’s expanded Medicaid coverage, which currently assists approximately 20 million Americans, according to the Kaiser Family Foundation (KFF). Joan Alker, the executive director of Georgetown University’s Center for Children and Families, emphasized that the passage of this bill—coupled with the expiration of enhanced subsidies— would significantly undermine the ACA's vision of achieving universal health coverage in the United States.
While President Trump has consistently claimed that his plan does not aim to cut Medicaid, the drastic reductions forecasted in coverage contradict Republican assertions of limited cuts. Vice President JD Vance has urged fellow Republicans to prioritize the bill's immigration measures over criticisms concerning the Medicaid provisions. He stated that aspects like the CBO score and Medicaid policy details are secondary to the immigration enforcement funding included in the package.
The ACA has provided health care coverage to approximately 44 million people through its Medicaid expansion and health insurance marketplaces. Since its enactment in 2010, Republicans have sought to repeal the ACA, but a failed attempt during Trump’s first term revealed the potential political repercussions of such actions. Following opposition from key figures, including Senator John McCain, GOP leaders have previously deemed the issue politically toxic.
Currently, the proposed tax and spending legislation aims to formalize trillions in tax cuts from Trump’s initial term, primarily benefiting wealthier individuals, alongside substantial funding for immigration enforcement and defense. The Republicans plan to finance these initiatives largely through cuts to Medicaid. If enacted, this legislation would represent the most significant cuts to Medicaid in its nearly 60-year history, slashing over $1.1 trillion from federal funding allocated to Medicaid, Medicare, and ACA marketplaces.
Some Republican senators, including Thom Tillis (North Carolina) and Josh Hawley (Missouri), have expressed trepidation regarding the potential impact of these cuts on their states, particularly concerning rural hospitals that may face closure or significant service reductions. Tillis has publicly opposed the bill due to its impact on Medicaid, stating that it contradicts Trump's commitment to protect the program.
Additionally, Trump’s proposal introduces stringent work and reporting requirements for Medicaid that could disenfranchise millions from their health insurance coverage, including individuals who may qualify for exemptions. Adults aged 19 to 64 would need to fulfill at least 80 hours of qualifying work per month to retain their coverage, a challenging requirement for many in areas with limited job opportunities or those reliant on seasonal work. State-level administrative capacities to manage these new reporting demands are also in question.
The Senate's inclusion of measures that restrict financing options for hospitals could further exacerbate the situation, resulting in an additional $375 billion cut in federal Medicaid spending. Experts, like Allison Orris from the Center on Budget and Policy Priorities, warn that the bill's implications could mirror the detrimental effects seen in previous repeal attempts. As concerns mount regarding this legislation, it is clear that the future of health care coverage hangs precariously in the balance.
