Of Musk, Trump, Medicaid, Medicare, The ACA, And The Uninsured
The budget reconciliation saga continues a day after Elon Musk attacked the bill as “a disgusting abomination.” The president leapt into action, trying to convince Senate conservatives to support the package with promises of later spending cuts.
The bill hit another pothole today with a new Congressional Budget Office (CBO) score that said the bill will mean more than $1 trillion in cuts over a decade. This is higher due to the last-minute changes made in the House to obtain enough conservatives to pass the bill. The biggest hit comes in Medicaid, with a revised reduction of $864 billion. Work requirements save $344 billion after the House accelerated the provision to no later than December 21, 2026.
What’s more, the CBO projects that the Medicaid cuts and other healthcare reductions in the bill will lead to 10.9 million people becoming uninsured, including 7.8 million who would lose Medicaid benefits.
In general, the uninsured rate swells due to:
- The Medicaid policy changes, which include work requirements, limitations on state provider taxes to generate the state matching contribution, and various enrollment changes and restrictions, among other changes. Medicaid is about $864 billion over ten years in savings. About 7.8 million lose Medicaid due to the bill’s Medicaid provisions.
- Several policies impacting the Affordable Care Act (ACA) that would change premium tax credits for migrants, increased recoupment of premium subsidies paid out at levels that are too high from income, and increased eligibility checks. These ACA changes save about $230 billion over ten years. About 3.1 million lose coverage due to the bill’s ACA provisions and some other provisions.
The CBO also said that about 4.2 million will exit the Exchanges and remain uninsured due to the expiration of the enhanced premium subsidies at the end of 2025.
An additional approximate 900,000 would lose Exchange coverage as a result of a proposed Trump administration rule issued in March that would shorten the annual enrollment period, require stricter eligibility reviews, and make other changes.
This brings the total increase in the number of uninsured to 16 million by 2034.
Moderate and pragmatic conservative GOP senators appear to be willing to support Medicaid work requirements, but are very worried about other changes, especially the provider tax limitations and constraints on state directed payments. They worry about the fallout on providers, especially rural hospitals.
State officials who run the Exchanges urged the GOP to reject the ACA policy shifts, including new enrollment verification requirements and restrictions on tax credits. They say those changes in concert with expiration of the premium subsidies will upend state-based insurance exchanges by increasing costs, adding administrative burdens to states and consumers, stripping states’ decision-making authority, and destabilizing the program. The officials say in some states more than one in three could lose coverage.
A new Robert Wood Johnson analysis also finds that healthcare providers would lose more than $770 billion in revenue over the next decade under the bill.
Senate Republicans are now looking at whether the caucus would support fraud, waste, and abuse (FWA) in Medicare to add to reductions and possibly alleviate some of the Medicaid cuts. This is where I predicted Medicare Advantage (MA) risk adjustment reforms might be put on the table.
Additional articles: https://www.modernhealthcare.com/politics-policy/tax-bill-medicaid-cuts-cbo-gop and https://www.medpagetoday.com/publichealthpolicy/washington-watch/115901 and https://thehill.com/policy/healthcare/5332414-congressional-budget-office-estimate-health-insurance-losses-gop-megabill/ and https://insidehealthpolicy.com/daily-news/provider-taxes-state-directed-payments-sticking-points-among-gop-senators and https://insidehealthpolicy.com/daily-news/state-exchange-officials-urge-senate-leaders-reject-house-bill and https://insidehealthpolicy.com/daily-news/naic-urges-senate-leadership-change-or-delay-exchange-related-policies and https://www.fiercehealthcare.com/regulatory/state-exchange-directors-press-senators-extend-aca-tax-credits and https://www.rwjf.org/en/insights/our-research/2025/05/reconciliation-bill-and-end-of-enhanced-subsidies.html?cid=xsh_rwjf_li
(Some articles may require a subscription.)
#budgetreconciliation #trump #congress #medicaid #coverage #medicare #medicareadvantage #aca #obamacare #exchanges #providers #uninsured
https://thehill.com/homenews/senate/5333247-senate-gop-medicare-trump-tax-bill/
— Marc S. Ryan
