xpostfactoid

Friday, June 20, 2025

Republicans make the "abled-bodied" vulnerable

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Community engagement requirements for the "able-bodied"

Republican legislators who wrote the Medicaid provisions of their monstrous megabill are acting on a simple belief: low-income nonelderly adults who lack access to affordable employer-sponsored health insurance should not have access to affordable health coverage.

While their $900 billion* in cuts to federal spending on Medicaid over ten years will hurt all classes of Medicaid enrollees, the cuts are aimed primarily at low-income adults insured through the ACA Medicaid expansion — that is, adults under age 65 who are not recognized as disabled by the federal government (though many have varying degrees of disability**). Some cuts not aimed directly at the ACA expansion population target states that have enacted the expansion.

Provider tax cut aimed at expansion states

The major new spending cut added by the Senate Finance Committee to the House package last week is a case in point. Section 71120 would sharply reduce the revenue that Medicaid expansion states derive from “provider taxes,” a financial maneuver, allowed for decades, that all states except Alaska employ to boost Medicaid revenue and fund services. Under current law, states are allowed to hold taxed healthcare providers “harmless” if the taxes don’t exceed 6% of revenue — that is, they can boost payment to an amount equivalent to the revenue collected. Since the federal government pays its standard Medicaid share of the resulting new spending, varying from 50-77% by state, states can use the federal share to further boost spending. Most such taxes are imposed on nursing homes (46 states) and hospitals (45 states).

That financial maneuver is a classic American “kludge” — a workaround chronic Medicaid underfunding initiated by state governments and accepted by CMS. A responsible legislature looking to end such haphazard, convoluted funding mechanisms might replace the revenue from them, built into state budgets, with a more rational funding source. The House bill put a ban on new provider taxes, leaving current arrangements in place. The Senate Finance Committee takes a deep slice out of the revenue, cutting current taxes — but only for Medicaid expansion states. For those states, the “safe harbor” under which hospitals and other providers can be held harmless is cut by 0.5% per year from the current 6% until it hits a floor of 3.5% (nursing homes are exempted from the lower threshold).

As Georgetown’s Edwin Park notes (citing KFF data), at present 18 expansion states imposes taxes on hospitals above the 3.5% future safe harbor, and some of those states explicitly earmarked that revenue*** to fund the state’s share of the cost of enacting the ACA Medicaid expansion— potentially endangering maintenance of the expansion in those states if this provision is enacted. At the same time, six of the ten nonexpansion states (Alaska, Kansas, Mississippi, South Carolina, Tennessee and Texas) impose taxes on hospitals greater than 3.5% and would be exempt from this cut.

Republicans' hands-free healthcare cuts: Make enrollees self-deport from Medicaid and Obamacare

Third and probably last in a series from me at nj.com. Gift link.
Why N.J.’s Republicans in Congress are OK with 16M Americans losing insurance

Thursday, June 05, 2025

Republicans poised to halve the ACA cake and eat it

There’s a sad symmetry to the Congressional Budget Office’s final estimate of the coverage effects of the healthcare provisions in the monstrous megabill that passed the House with no Democratic votes on May 22.

In March 2011, CBO estimated that by 2021, the ACA would reduce the uninsured population by 34 million — 17 million via Medicaid, and 17 million via the subsidized ACA private-plan marketplace. (Below, note the net gain in the individual market: 24 million enrolled in the exchanges established by the ACA, minus 6 million in the off-exchange market and another 1 million in employer-sponsored plans.)

After waves of political upheaval, including a major boost to marketplace subsidies in 2021 (now apparently doomed to expire at year’s end), those estimates look pretty good. In Medicaid, 16.6 million enrollees as of June 2024 (the last available tally) were rendered eligible solely by the ACA expansion, and total Medicaid enrollment as of January 2025 is up by 22 million over the last pre-ACA total. As for the marketplace, enrollment as of the end of Open Enrollment 2025 was 24.3 million, with perhaps another 2 million off-exchange, compared to total individual market enrollment of 10.6 million pre-ACA, by KFF’s estimate.

Today, in a narrative breakdown of its estimates sent to ranking Democrats in the key House and Senate committees, CBO forecasts an increase of 16 million uninsured people triggered by the House bill coupled with Republican refusal to extend the ACA subsidy increases enacted in 2021 and funded only through 2025. Like the coverage gains triggered by the ACA, these coverage losses would split almost evenly between coverage losses triggered by the bill’s changes to Medicaid and its changes to rules governing the ACA marketplace. Here is the breakdown:

Changes to Medicaid are forecast to increase the uninsured population by 7.8 million, and changes to the ACA marketplace, by 8.2 million.

A multi-pronged assault on health coverage for immigrants

You look able-bodied -- and you want health coverage?

6/4/25: See updates/corrections below regarding marketplace eligibility for immigrants subject to the 5-year bar for Medicaid eligibility, along with CBO estimates of coverage losses among immigrants in the ACA marketplace.

There is so much to lament in the healthcare provisions included in the legislative monstrosity that passed the House with no Democratic votes on May 22. By CBO’s conservative estimate, provisions affecting Medicaid and the ACA marketplace will reduce spending by about $900 billion over ten years and increase the uninsured population by about 11 million — 15 million if you count Republicans’ refusal to extend the enhanced ACA premium subsidies created by the American Rescue Plan and funded only through 2025.

Reliable scholars have detailed the likely effects of Draconian work reporting requirements and more frequent redeterminations in Medicaid, and of the miles of red tape wrapped around prospective ACA marketplace enrollees, which impose unsustainable cost and risk on many enrollees (Jonathan Cohn has just published a painfully good overview of the bill’s assault on the marketplace).

Here I want to focus on the legislative aggression unleashed on immigrants — lawfully present as well as undocumented.

With ARPA subsidies set to expire, a window on the ACA's off-exchange market

A press release from New Jersey’s Department of Banking and Insurance (DOBI) urging Congress to extend the enhanced ACA marketplace subsidies created by the American Rescue Plan Act (ARPA) in 2021, which are funded only through this year, led me to discover that DOBI has resumed quarterly tracking of off-exchange as well as on-exchange enrollment, after a long hiatus (1-2 years?). Reports are now available through Q2 2024.

In general, nationally, off-exchange enrollment data is spotty, and the off-exchange enrollment numbers in NJ open a window into how expiration of the ARPA-enhanced subsidies, which Republicans are unlikely to extend, may affect those with income above 400% FPL, the once and likely future cap on subsidy eligibility. In the Open Enrollment Period (OEP) for 2021, the last year with the 400% FPL cap on income eligibility, 43% of state enrollees in ACA-compliant plans were unsubsidized. In 2024, just 25% were unsubsidized. We will probably soon be back to 40%-plus.

Republican bill imposes major new out-of-pocket costs on the near-poor

The draft legislation released by the House Energy and Commerce Committee on Sunday night (May 11) gnaws at Medicaid and marketplace spending from so many angles and inhibits enrollment in so many ways, it’s hard to know where the bulk of the enrollment reductions and benefit degradation will come from. By CBO’s preliminary estimate, the Medicaid and marketplace provisions will cut federal spending by $715 billion over ten years and increase the ranks of the uninsured by 13.7 million (if you include failure to extend funding for the enhanced marketplace subsidies provided by the American Rescue Plan Act, which are funded only through this year; expiration of those subsidies accounts for 4.2 million of the coverage losses).

On the Medicaid side, work requirements (a.k.a. red tape requirements) have been clearly shown to drive eligible people off the rolls without boosting employment. Work requirements may account for more than half of the 7.7 million reduction in Medicaid enrollment that CBO forecasts, based on prior Urban Institute estimates (CBO has not yet itemized its Medicaid enrollment loss estimate by provision). Increasing the frequency of redeterminations and suspension of Biden administration rules designed to streamline enrollment would also take a significant toll on enrollment.

Here I want to focus on a double-barreled assault imposing a different form of harm: increased out-of-pocket costs for those who do enroll in coverage, in particular those with income a step above poverty, i.e. 100-138% of the Federal Poverty Level (FPL). In the 2025 ACA marketplace, which uses prior-year FPL, that’s income up to $20,783 for an individual, $43,056 for a family of four. For Medicaid, which uses current-year FPL, the thresholds are 3.9% higher. In the marketplace, we’ll also look at the broader 100-150% FPL bracket, since benchmark silver plans are available at zero premium up to 150% FPL under the enhanced subsides.

CBO lowballs coverage losses if Republicans defund the ACA Medicaid expansion

Cuts may be more unkinder than portrayed

As Republicans in the House and Senate continue to tussle over various options for cutting hundreds of billions of dollars in federal Medicaid spending, the Congressional Budget Office has dropped a gift for those who favor defunding the ACA Medicaid expansion.

The ACA expansion, which the Supreme Court made optional for states, opens Medicaid to adults with income below 138% of the Federal Poverty Level. To make that coverage affordable for states, the ACA established a permanent 90% Federal Medical Assistance Percentage (FMAP) for those rendered eligible by the expansion. For other Medicaid eligibility categories — children, Aged, Blind and Disabled, and low-income seniors, the federal FMAP ranges by state from 50-77%, varying according to state per capita income.

In a report released yesterday estimating the fiscal and coverage effects of five Medicaid cost-cutting options Republicans are considering,* CBO produced surprisingly low estimates of the coverage losses that would result from Republicans defunding the ACA Medicaid expansion.

Of the five cost-cutting options CMS considered,* I want to focus first and foremost on two of them:

Option 1 would repeal the ACA expansion’s 90% Federal Medical Assistance Percentage (FMAP), paying only each state’s match rate for all other populations (ranging from 50% to 77%) for the expansion population (adults with income below 138% FPL).
Option 4 would impose a per-enrollee inflation cap on federal spending for the ACA expansion population alone. KFF estimates that such a “per capita cap, using the most likely inflation measure (CPI-U plus 0.4%), would ratchet the expansion FMAP down to 69% by 2034.

According to CMS’s most recent tally (June 2024), the federal government pays the 90% FMAP for 20.9 million adults rendered eligible by expansion criteria (income under 138% of the Federal Poverty Level).**

CBO estimates that repealing the expansion’s 90% FMAP outright would reduce Medicaid enrollment by 5.5 million and increase the uninsured population by 2.4 million. Imposing per capita caps on the expansion population would reduce enrollment by 3.3 million and increase the ranks of the uninsured by 1.5 million.

Those estimates assume that most states will not end eligibility for the expansion population — whether quickly, if the 90% FMAP is repealed outright, or somewhat more slowly, if it’s eroded over time by per capita caps. That’s surprising.

The estimates “do seem low,” Larry Levitt of KFF told me in an email. Matt Fiedler of the Brookings Institute agreed. “I think they are on the low side. I think I would bet on states cutting back more aggressively, although I think it’s also fair to say that there is a lot of uncertainty here.” Edwin Park of Georgetown University wrote, “CBO is likely overly conservative here because it's unlikely that states in reality would be able to replace half of the cost shift in the face of all of these cuts.”

Park’s last point is key. Explaining the basis of its estimates, CBO spells out its assumption that “on average, states would replace roughly half of the reduced funds with their own resources.”

That assumption raises expert eyebrows. By CBO’s estimate, eliminating the ACA’s 90% match rate for the expansion population would reduce federal payment to states for expansion enrollment by $860 billion over ten years. That total includes the effects of states reducing benefits and provider payments. The ten-year federal payment reduction before state response is estimated at $516 billion.

All states but Alaska are required by their Constitutions or state law to balance their budgets. By KFF’s estimate, the 40 states (plus D.C.) that have enacted the expansion collectively would have to spend $626 billion over ten years to make up the federal shortfall resulting from repeal of the ACA’s 90% FMAP. New Jersey has estimated the annual cost of FMAP to the state budget at $2.2 billion (in an annual budget of $56 billion). As anyone who’s followed any state’s annual budget deliberations can testify, states don’t raise billions in new revenue lightly. It is highly questionable whether any state would be able to maintain the expansion in its entirety at the state’s own FMAP (especially wealthy states, where the FMAP is just 50% or slightly higher). On May 1, prior to the CBO report release, Park assessed the odds as follows:

Faced with such massive cost shifts under these proposals alone [90% FMAP repeal or per capital caps for the expansion group], states would either have to dramatically raise taxes, cut other parts of their budget like education, deeply cut the rest of their Medicaid program, or as is most likely, eventually drop the expansion.

It’s possible that a handful of determined Democratic-led states would maintain the expansion for enrollees with income up to 100% FPL (as Wisconsin does at present, without the 90% FMAP), which would place those in the 100-138% FPL bracket into marketplace coverage, for which the federal government pays 100% of the cost. But those blue states are also mostly wealthy states with low FMAPs — e.g., 50% for California, New York, Illinois, and others.

Under the assumption that no state would maintain coverage to 138% FPL, enrollment declines would likely top 15 million.

In fact, 12 states have “trigger” laws requiring them to end the expansion if the expansion FMAP is reduced. While there is some ambiguity and flexibility in how some states might interpret those triggers, Georgetown’s Adam Searing notes that nine of them would all but certainly have to terminate coverage immediately if the expansion’s 90% FMAP is repealed. Should all of them do so, the Center for American Progress has tallied the enrollment losses at 3.6 million. (Subtract the three states with more flexible triggers — Idaho, Iowa and New Mexico — and the total is 3.1 million.) Under CBO’s estimate, that would suggest coverage losses in 28 non-triggered states of just 2-odd million.

It seems unlikely that losses would be that low. CBO’s estimates virtually assume that the expansion would be maintained in high-population states such as California (which has 5 million expansion enrollees), New York (2.1 million), Illinois (843,000), and Pennsylvania (832,000).

Per capita caps

Capping payments for the expansion population would ratchet down the expansion FMAP annually rather than in one fell swoop. As mentioned above, KFF estimates that the FMAP would drop to 69% over ten years — and, I would add, would continue to drop in a second decade, assuming that any policy in the U.S. remains stable for that long. Because the damage is incremental, the ten-year cost deficit reduction estimate is far lower ($225 billion vs. $710 billion) — but the ultimate effect on coverage should be more or less the same (or worse in future decades, if the caps are not removed). It’s hard to imagine states maintaining coverage to 138% FPL with an FMAP under 70%.

Other options

CBO Option 3, imposing per capita caps on federal spending for the entire Medicaid population, appears to be off the table. As to Option 5, repeal of an array of Biden administration administrative measures designed to reduce friction in the application process and churn in enrollment, I have no comment, except that this repeal would be (will be, sigh) very unfortunate. Reducing administrative barriers to enrollment is a slow boring of hard boards.

Provider tax wipeout?

Option 2, limiting state taxes on health care providers (or rather, limiting payback to those providers) bears some consideration.

Provider taxes are a financial maneuver through which states plus up their federal Medicaid contribution. If a tax on a provider class does not exceed 6% of the provider’s net revenues, the state can essentially give the tax dollars back to the provider group in the form of higher payments — and receive its federal FMAP (ranging by state from 50-77%) for the extra payments.

Right-wing Paragon Health Institute head Brain Blase, deploying Gingrichian rhetoric, calls these maneuvers “money laundering.” In fact they’re the kind of kludge that state-federal partnerships and U.S. political sclerosis routinely generate: a workaround to compensate for chronic underfinancing of Medicaid, which keeps payment rates below Medicare rates and below cost for providers in many categories and places. States must propose such arrangements to CMS before implementing them, and CMS must assess the proposal and approve it. These taxes are legal, and states depend on them.

Repealing states’ ability to hold the taxed entities harmless — that is, to essentially pay the tax back, largely with federal dollars — would be very expensive for states. CBO estimates the deficit reduction effect of complete repeal of the ‘hold harmless’ option at $668 billion over ten years — nearly the same as savings from repealing the ACA FMAP ($710 billion). The gross reduction in federal outlays is slightly higher than for ACA FMAP repeal. The coverage loss estimate also is higher — 8.8 million.

The catch is that a complete wipeout of the provider payment option is highly unlikely. A more realistic option is to reduce the threshold (“safe harbor”) under which the taxed entities can be held harmless from the current 6% of revenues. A prior CBO estimate pegs the 10-year federal savings from reducing the safe harbor threshold to 2.5% at $241 billion. There would be large variation in how this measure would affect states, as the number of provider taxes and thresholds states use varies widely.

In connection with the provider taxes, Park’s analysis of the likely effects of Republican proposals makes two important points. First, a dozen states by Park’s count fund their 10% share of the ACA expansion cost via provider taxes. “Restricting provider taxes,” Park writes, “could by itself prevent some expansion states from continuing to directly rely on this state financing source for the expansion. If such states were unable to identify other revenues, they would have no choice but to eliminate their expansion.”

Second, as the last point illustrates, any combination of cuts will have a cumulative effect. As Park put it in an email to me, “With multiple cost-shifts, it's hard to see how states can compensate for any of them in combination.” CBO perhaps had to consider the five options for which Wyden and Pallone requested analysis (see note at bottom) in isolation, because they are not part of an actual bill, and no one knows which, if any, Republicans will put into legislation. But that limitation will likely limit stakeholders’ perception of the damage these cuts may inflict as they consider CBO’s projections.

- - -

* CMS considered these five options at the request of Democrats Ron Wyden, ranking member of the Senate Finance Committee, and Frank Pallone, ranking member of the House Energy & Commerce Committee.

** Of those, 4.3 million would have been eligible under pre-ACA eligibility criteria in a handful of states that obtained waivers to expand coverage, with the largest numbers in New York (1.8 million, Puerto Rico (634,000), Massachusetts (393,000) and Louisiana (216,000).

Sunday, May 04, 2025

In the drive to gut Medicaid, spotlight on Jeff Van Drew (NJ-2)

Pink tie/weak MAGA?

See updates for 5/6/25 and 5/7/25 at bottom.

I have an op-ed in NJ.com questioning whether Rep. Jeff Van Drew (R-NJ-2) will hold to his promise to “protect” Medicaid for his constituents, including those covered via the ACA Medicaid expansion.

Van Drew, a formerly Democratic House representative in South Jersey who went MAGA and switched parties, has been something of a fulcrum in the Republican House drive to pass legislation cutting hundreds of billions of dollars in federal Medicaid funding (he’s at least a frequent source in reports on that struggle).

On the one hand, Van Drew has more than 165,000 Medicaid/CHIP enrollees in his district, including more than 50,000 low-income adults covered via the ACA Medicaid expansion. Unlike most Republicans, when he vows to “protect” Medicaid, he includes “low-income families” — i.e., the ACA expansion population — in the groups to be protected. And yet, he voted for the resolution targeting hundreds of billions of dollars in cuts to Medicaid over ten years. And there are signs he will go along with essentially repealing the expansion - -that is, cutting federal funding for it enough to make it fiscally impossible for states to continue.

The op-ed spotlights the contradictions in Van Drew’s words and deeds concerning Medicaid and encourages constituents (and perhaps reporters) to press him about those contradictions. I hope you’ll give it a read.

We're not cutting federal spending, we're just reducing it

Cut? What cut?

Regarding Republican plans to cut (or theoretically, not cut) federal funding for the ACA Medicaid expansion: What’s funky about this narrative from Ben Leonard in Politico?

Some moderate Republicans and vulnerable GOP incumbents have signaled opposition to cuts to the program itself but have left the door open to supporting a reduction in the federal share of payments to the expansion states.

That’ a self-cancelling statement. A “reduction in the federal share of payments to the expansion states” is the only type of cut to the program under consideration. You can’t “oppose cuts to the program itself” and cutting federal funding for it. While the letter from twelve House moderates to leadership purported to exactly that, their obfuscation shouldn’t be reported as possible.

The ACA stipulated that the federal government would pay 90%* of the costs of enrollees rendered eligible by the expansion — adults under age 65 and not on disability with income below 138% of the federal poverty level — because expanding eligibility in that way would be unaffordable for states under their normal federal match rates (deemed the Federal Medical Assistance Percentage, or FMAP).

That remains true today. If the 90% FMAP for the expansion population is repealed, so that each state is only reimbursed at the FMAP it receives for other Medicaid populations (ranging from 50% for high-income states to 77% for the lowest-income states), no state will able to afford the full expansion. The 50-state 10-year tab would total $626 billion, according to KFF. Some states with progressive governments might extend eligibility to all or most adults with income up to 100% FPL, as a handful did before the ACA expansion was enacted. But that’s about it. Repealing the ACA’s 90% FMAP for the expansion population will, over the course of a handful of years at most, strip Medicaid coverage from most-to-all of the 21 million adults currently covered (or those who would replace them — Medicaid has a lot of turnover).

Leonard’s formulation above has some technical accuracy in that Republicans theoretically could cut all federal funding for those rendered eligible for Medicaid only by expansion criteria — effectively barring coverage for most adults not on disability in many states. But that was never on the table. By CBO’s estimate, reducing the FMAP for the expansion population to the FMAP for all other eligible populations in that state, would reduce spending by $561 billion over 10 years. That’s the lion’s share of the $880 billion/10 year cut target established by the budget resolutions under which Republicans are writing their spending bills.

Recently, a lesser but still damaging cut the expansion FMAP has been floated: Republicans could impose a per capita cap on funding for the expansion population alone, which would mean that funding each year increases at a rate below that of likely medical inflation (and would fall radically short in a crisis like the COVID-19 pandemic, during which Medicaid held the line against mass increases in the uninsured population). KFF estimates that this cut would cost states $246 billion over ten years. Worse, the FMAP would keep dropping so the effects compound over decades. And again, there are no contemplated “cuts to the program itself” other than cuts to the FMAP.

Well, check that: imposing work requirements, which impose onerous reporting requirements on enrollees and therefore drive eligible people off the rolls (by design), are an indirect cut, aimed primarily at the expansion group, and supported by virtually all Republicans. But they wouldn’t call this barrier to enrollment a “cut to the program.

Promising not to cut benefits while defunding the expansion is an economic iteration of the party line, articulated by House Energy and Commerce Chair Brett Guthrie and effectively seconded by House Speaker Mike Johnson, that the expansion of eligibility to the “able-bodied” diverts resources from "the disabled, the destitute, the people that Medicaid was originally designed for" — and defunding it is therefore strengthening Medicaid.

As I noted two weeks ago (time flies when you’re gutting vital programs), the April 14 letter from twelve Republican House “moderates” to leadership (alluded to in the Politico passage above) purportedly balked at steep Medicaid cuts, asserting in the first paragraph, “Balancing the federal budget must not come at the expense of those who depend on these benefits for their health and economic security.” But actually the letter endorses cutting the expansion, excluding the low-income adults insured through the expansion from the groups the signers vowed to protect (my italics):

We support targeted reforms to improve program integrity, reduce improper payments, and modernize delivery systems 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. However, we cannot and will not support a final reconciliation bill that includes any reduction in Medicaid coverage for vulnerable populations.

This gaslighting is still widely misunderstood; every day I read assertions (as above) that the letter’s signers are balking at major cuts.

- - -

UPDATE, 5/1/25: More no cuts/just reductions nonsense, via Punchbowl:

A. "Moderates" are "concerned"...

GOP moderates concerned about Medicaid cuts will meet with House Energy and Commerce Chair Brett Guthrie (R-Ky.) this week as the panel struggles to come up with potentially hundreds of billions of dollars in cuts to the popular program.
Rep. Jeff Van Drew (R-N.J.) told us this will be his fourth conversation with Guthrie, who has been talking to concerned members individually for weeks. Van Drew was among a dozen Republicans who warned House GOP leaders that they wouldn’t vote for a final reconciliation package with deep Medicaid cuts.
“We’re going to hold their feet to the fire to make sure there isn’t a lasting change,” Van Drew told us. “Attitude is what matters most here. We’re not just going to roll.”

B. "Moderates" will gut the ACA expansion...

Guthrie said the panel is still considering whether to lower the federal match rate or implement per capita caps for the ACA Medicaid expansion population.
GOP moderates are more supportive of changes to the expansion population, with Bacon, Van Drew and Malliotakis saying they would consider those proposals. However, this may cause issues in the Senate.

C. Susan Collins deploys Congress-speak to make it clear that she does not want to defund coverage for the expansion population (though she will cut it via work requirements):

“The one thing that I would support are carefully crafted work requirements for able-bodied adults without pre-school children,” Collins said. “But I want to make sure we’re not depriving seniors, children, low-income families, people with disabilities and our rural hospitals.”

No one likes to say "low-income adults" -- who could care about them? So "low-income families" is the universal designation of the ACA expansion population. It's not exactly inaccurate, as a family is hurt by stripping healthcare access from its adults. [End update]

The ACA was built on “kludges” — patches laid on an existing patchwork of programs and practices. There is no inherent reason for the FMAP for the expansion population to exceed that of the FMAP for the disabled, children, and the low-income elderly. In a political world where rational policy were possible, each state’s FMAP might be blended and unified in a revenue-neutral way. (Or better yet, the federal government would assume complete responsibility for the program, as for Medicare.) But that is not going to happen. Meanwhile, the expansion has served as the chief engine for the ACA cutting the uninsured rate in half since inception. (The ACA marketplace, enhanced by the increased subsidies enacted by the American Rescue Plan Act in 2021, may recently have reached rough parity with the expansion in reducing the ranks of the uninsured — but those enhanced subsidies expire at the end of this year unless Republicans extend them.)

Extending Medicaid coverage to 21 million low-income adults has been a major policy accomplishment, vastly increasing national well-being. To borrow a short list of benefits from Jason Sattler (aka LOLGOP):

It cuts crime, especially drug arrests.
It increases families’ entire financial well-being.
It creates jobs.
It helps hospitals.

So of course Republicans want to kill the expansion. They just don’t want you to notice.

*Originally 100%, phased down over three years.

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Wednesday, April 23, 2025

Cut Medicare, not Medicaid

As soon as House Republicans’ budget resolution was published, it was clear that almost all of the $880 billion 10-year spending cut target for the Energy and Commerce Committee would have to come out of Medicaid, because Medicaid accounts for 93% of projected 10-year spending under E&C’s purview — excluding Medicare. And Medicare, unlike Medicaid, is a sacred cow.

That’s too bad, because while the cuts that Republican lawmakers are proposing to Medicaid funding will likely cause 10-20 million people to lose coverage, federal payments to private Medicare Advantage plans, which now enroll 54% of Medicare beneficiaries, can and should be cut by something in the neighborhood $880 billion over ten years — a reduction that would still leave the plans overpaid.

Don’t ask me, ask MedPAC, the Medicare payment advisory commission that reports annually to Congress on Medicare spending. According to MedPAC’s March 2025 report, “In 2025, we estimate that Medicare will spend 20 percent more for MA enrollees than it would spend if those beneficiaries were enrolled in FFS Medicare, a difference that translates into a projected $84 billion.” Projecting that estimate forward, the Committee for a Responsible Federal Budget estimates that MA plans will be overpaid by $1.2 trillion from 2025-2034.