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Death by a Thousand Cuts: The GOP's Stealth Move to End the ACA
Health care analyst Charles Gaba estimates that at least 15 million people could lose Medicaid coverage if congressional Republicans get their way.
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So, congressional Republicans have decided that they MUST cut Medicaid spending by anywhere between $500 billion to $880 billion over the next decade. Why? Because if they don't, they won't be able to continue giving massive tax cuts to billionaires, and of course that's something which must happen for reasons unknown. To them, the alternative (namely, not kicking up to millions of Americans off their health care coverage) is simply crazy talk.
While congressional Republicans are quick to point out that technically the word "Medicaid" isn't included in the resolution itself, simple math makes it clear that there's absolutely no way to achieve that type of federal spending reduction without absolutely gutting Medicaid one way or another.
A few months back, House Republicans tossed around a half-dozen or so different ways they could achieve their goal, and in recent weeks it looks like they've pretty much boiled them down to three:
Eliminating the higher federal match rate for ACA expansion enrollees
Imposing per capita caps on ACA expansion enrollees
Imposing work reporting requirements on ACA expansion enrollees.
The common thread across all of these is the target population: Medicaid enrollees who weren't eligible for Medicaid prior to the Affordable Care Act's expansion of eligibility being implemented in 2014 … otherwise known as so-called "able-bodied" adults age 19 to 64 who earn less than 138% of the Federal Poverty Level (roughly $21,000 per year for a single adult.)
Ten states still haven't taken up this expansion, but across the 40 (plus D.C. & some U.S. territories) which have, there's roughly 21 million Americans enrolled in Medicaid via the ACA expansion provision.
As I noted last week, Republicans have decided that this is the perfect target because they think it'll play well politically: The optics look a lot better, the logic goes, to tear health care coverage away from "young men who need to be out working instead of playing video games all day," as House Speaker Mike Johnson put it, than from children, the elderly or disabled folks who are apparently more "deserving."
Never mind the fact that the vast majority of those on Medicaid via ACA expansion are ALREADY either working, in school, caregivers for relatives or are actively seeking employment. Johnson and congressional Republicans have decided that they're the new welfare queens — lazy couch potatoes just sitting around playing “Grand Theft Auto” while soaking up that sweet, sweet free health care from the taxpayer teat (Musk’s and Bezos' billionaire teats are dry some years, I should note.)
Going after the expansion population specifically would have two ancillary benefits to congressional Republicans, as well. First, it wouldn't hit the 10 states which haven't expanded the program under the ACA … eight of which are under complete GOP control.
Second, technically they don't have to "officially" remove anyone's eligibility at the federal level. The first two of the strategies above (lower match rate and per-capita caps) are designed to simply shift an impossible-to-cover chunk of the cost of expansion onto the states ("Hey, don't blame us, blame the governor!") And the third (work requirements) puts the burden onto enrollees if they fail to keep up with the Kafkaesque reporting rules.
It's important to note that a dozen states have "trigger laws" in place that would require the state to either automatically terminate Medicaid expansion if the federal match rate ever falls below the ACA-guaranteed 90% or to make other drastic changes to it. Some states (particularly the blue ones) would probably try to mitigate the damage via shifting money around, imposing new taxes/fees and so on. Others might try to keep the number covered the same while reducing the scope/quality of services included with Medicaid coverage.
However, most of these measures would only mitigate a small portion of the lost federal funding, while others would likely only last a year or two before having to be shuttered.
In any event, I'm a numbers guy so here's the best estimates I have of just how many people would be screwed. And for my purposes, I have to operate on the assumption that all 50 states and D.C. would be forced to completely abandon Medicaid expansion.
As of June 2024, there were 20.9 million Americans enrolled in Medicaid via ACA expansion nationally (including U.S. territories.) Of those, around 4.3 million were previously eligible for Medicaid in some states via pre-ACA laws or federal waivers, so we're really looking at perhaps 16.7 million people who would lose Medicaid coverage, which is still horrific.
Over at the Urban institute, health care policy analyst Matthew Buettgens projected in February that the actual number would be more like 15.9 million for various reasons. Of those, he figured that perhaps 2 million or so would gain coverage by shifting to subsidized ACA exchange coverage (there's an income overlap at the upper end of expansion eligibility in non-expansion states), while another 3 million or so would likely gain coverage through their employer.
As a result, he projected that the actual number of Americans who would become uninsured as a result of ACA expansion being wiped out would be more like 10.8 million. Again, that’s still a grotesque number of people to lose health care coverage just so a handful of billionaires can buy another yacht.
I have three caveats to add to Buettgens’ excellent analysis.
First, it was published in February … before Elon Musk and his merry band of DOGE Incel Hitler Youth had ramped up firing hundreds of thousands of federal employees … many of whom are likely in the process of enrolling in Medicaid or ACA exchange plans right now.
Second, it was also published before Trump hosed the economy with his on-again, off-again cavalcade of tariffs and other weapons of economic mass destruction. There could be several million people who lose their jobs between now and whenever the Medicaid cuts go into effect. In many cases, they may be kicked off the program almost as soon as they've enrolled in it.
Third, his analysis is purely about Medicaid expansion and therefore doesn't even touch on the impact of the upgraded Inflation Reduction Act subsidies for ACA exchange enrollees being allowed to expire at the end of this year: Specifically, the 3.8 million people the Congressional Budget Office expects to become uninsured over the next decade as a result (including 2.2 million in 2026 alone.)
When you take those into account, you're looking at a minimum of about 20 million Americans losing Medicaid or ACA coverage with at least around 15 million of them becoming uninsured over the next few years … for absolutely no good reason.
Charles Gaba is a health care analyst who tracks policy and politics at ACASignups.net. He’s also runs Blue26.org, which makes it easy to donate to Democratic candidates at the federal, statewide and local levels.
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