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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
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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.
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| 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.
