As President Donald Trump’s domestic policy agenda moves forward to the U.S. Senate this week, health insurance coverage for millions of Americans hangs in the balance.
The budget deal, referred to as One Big Beautiful Bill, is a 1,038-page spending package that aims to cut taxes, increase military and border spending and decrease spending on federal benefits programs. Collectively, the bill will raise the national deficit by $2.4 trillion, according an analysis released Wednesday by the nonpartisan Congressional Budget Office, or CBO.
Under the deal passed by the U.S. House of Representatives last month, policy analysts are estimating between 10.9 million and 15 million people would lose access to their health insurance plans over the course of the budget window, which extends to 2034.
“We’ve never in history experienced coverage cuts of this size,” says Alice Burns, an expert on Medicaid and the uninsured at the nonprofit health policy center KFF. “That makes it really difficult to predict how states, providers and patients will respond.”
Most of the loss of coverage would stem from an overhaul of Medicaid, the public health insurance program for low-income Americans jointly run by states and the federal government. Currently, more than 71 million people are insured by Medicaid.
Several million more are also expected to lose their health insurance coverage through changes to the Affordable Care Act, aka Obamacare, combined with sunsetting provisions that the GOP megabill does not extend.
Republican lawmakers were quick to dismiss the CBO report Wednesday.
“This bill will actually reduce the deficit if you recognize the historical economical growth that has always been there,” House Majority Leader Steve Scalise, a Louisiana Republican, said.
Supporters of the deal contend that the health insurance provisions remove people who they say should not be covered.
Sen. Joni Ernst, R-Iowa, for one, told constituents in a contentious town hall meeting Friday that the reductions of people on Medicaid and Obamacare rolls are “corrections,” stating there are many people enrolled who she says shouldn’t be. “Illegals that are receiving Medicaid benefits — 1.4 million — they are not eligible,” Ernst said, repeating a misleading claim flagged by FactCheck.org. “They will be coming off.”
A constituent in the crowd yelled out: “People are going to die.”
“Well, we all are going to die,” Ernst replied. “For heaven’s sakes, folks.”
Ernst’s comments elicited ire from the audience and swift condemnation online and in the media.
On Monday, the White House published a memo that stated, “No, people will not ‘literally die’” due to the Big Beautiful Bill, adding that Medicaid will be “strengthened.”
How Medicaid could shrink (again)
Despite the White House’s claims of strengthening Medicaid, nonpartisan estimates show that the current budget bill reduces federal Medicaid spending by about $700 billion over 10 years, one of the largest cuts in the program’s history.
The reduction in spending comes in part from stricter work, enrollment and verification requirements to enlist — and stay on — Medicaid.
Currently, there is no federal work requirement to receive Medicaid benefits, although a majority of recipients are already working.
The proposal would change that by requiring childless Medicaid recipients to show proof in some form of employment or schooling for at least 80 hours a month. States would be banned from waiving this requirement and directed to increase the frequency and complexity of eligibility checks for ongoing coverage.
Already, the eligibility checks without an employment requirement keep many otherwise eligible Americans from receiving Medicaid benefits. Experts refer to this paperwork hurdle as “churn.” During the pandemic, paperwork requirements were relaxed, and Medicaid rolls ballooned to cover about 85 million people in 2023. As stricter verification checks returned, about 14 million people have lost coverage.
According to a survey from KFF, the vast majority of Americans — including 94% of Republicans — say Medicaid is important to people in their communities.
Some 62% said they generally support work requirements for Medicaid, but that number shrank when respondents were given information about how paperwork hurdles and work requirements may keep eligible Americans from receiving benefits.
When presented with the argument that most Medicaid recipients already work and that those who don’t work may be disabled or caregiving, only 32% still supported adding new work requirements.
According to a separate KFF analysis, the proposed changes to Medicaid would disproportionately affect certain states over others. Medicaid enrollment in over a dozen states, for instance, would shrink by over 15%, including major reductions in Washington (25%), Virginia (20%) and Kentucky (19%).
How Obamacare could shrink
According to a report from the Centers for Medicare & Medicaid Services (CMS), Obamacare hit a milestone earlier this year, covering a record-setting 24.3 million people. That progress may soon be undone.
If the current version of the Big Beautiful Bill becomes law, upwards of 6 million people are expected to lose their health insurance coverage through Obamacare, according to a preliminary estimate by the CBO.
The left-leaning Center on Budget and Policy Priorities places that number higher, projecting that more than 8 million people may lose health coverage due to the proposed changes to the Affordable Care Act.
The budget proposal affects Obamacare enrollees directly and indirectly.
Directly, the Big Beautiful Bill would shorten the open enrollment period by one month, moving the annual deadline to choose a health plan from January 15 to December 15 starting in 2026.
The bill also imposes stricter income verifications and eliminates special enrollment periods (outside the new December 15 deadline) for low-income earners. It would also end automatic re-enrollment, meaning that individuals would need to manually select their coverage each year during the condensed enrollment period in order to maintain health insurance.
The CBPP analysis found that these direct changes would prohibit nearly 4 million people from Obamacare coverage.
The remaining loss of coverage would come from expiring subsidies that keep insurance costs down for certain low- to moderate-income families. The Biden administration’s Inflation Reduction Act extended pandemic-era rules, which essentially discounted health insurance premiums for families earning up to 400% of the federal poverty line (roughly $62,600 for singles in 2025), but those provisions are scheduled to end at the close of the year.
The Big Beautiful Bill does not address the expiring subsidies, and as a result, health insurance premiums are slated to soar for millions of Americans. The CBO projects that this could lead to 4.2 million people losing their health insurance.
What’s next?
The ball is currently in the Senate’s court, and negotiations are heating up this week. The Trump administration has said it expects a ready-to-sign deal by July 4.
The Senate version of the bill could include revisions, but given the breadth of the package, it’s not clear yet how much focus health care will get.
“We don’t know what the Senate will do,” says Burns with KFF, “but assuming there are no major changes, we expect to see similar effects on coverage.”
For at least one Senate Republican, Josh Hawley of Missouri, Medicaid is a big sticking point.
Last month, Sen. Hawley wrote an op-ed in The New York Times titled “Don’t Cut Medicaid.”
“If Congress cuts funding for Medicaid benefits, Missouri workers and their children will lose their health care. And hospitals will close. It’s that simple,” he wrote. “And that pattern will be replicated in states across the country.”
Back in Ernst’s fiery town hall earlier this week, the Iowa senator indicated that the Senate version will indeed look different from the current proposal, although how different is difficult to say.
“It will change,” Ernst said. “The bill will be changing.”
“There are going to be some things we do agree on with the House,” she added. “Things like Medicaid.”
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