“Unraveling Health Coverage: The Impact of the House GOP’s Tax and Spending Legislation”

Experts warn that the House tax and spending bill could result in millions of Americans losing their health insurance, as Republicans aim to cut programs like Medicaid and the Affordable Care Act to accommodate President Donald Trump’s priorities, which include almost $4 trillion in tax reductions.

The Congressional Budget Office (CBO), a neutral legislative advisor, has estimated that around 11 million people could lose their health care coverage if the bill passed by the House of Representatives is enacted as is. Additionally, around 4 million more might become uninsured due to the expiration of Obamacare subsidies, which this bill does not renew.

The uninsured population could increase significantly due to measures that would impose stricter access conditions, hike insurance costs, and outright deny benefits to certain groups, including specific legal immigrants.

The legislation, dubbed the “One Big Beautiful Bill Act,” may undergo modifications as it reaches the Senate for consideration. Cuts to health care have proven contentious, with some Republican senators indicating they may not support Medicaid reductions, which could jeopardize the bill.

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The CBO projects the bill would add $2.4 trillion to the national debt over the next ten years, following over $900 billion in cuts from health care programs, according to the Penn Wharton Budget Model.

These cuts represent a drastic turnaround from the gradually increasing access to health insurance over the last 50 years, including through Medicare, Medicaid, and the Affordable Care Act, according to Alice Burns, associate director of Medicaid and uninsured programs at KFF, a nonpartisan health policy research organization.

“This could result in the largest reduction in health insurance we’ve ever seen,” Burns remarked. “It’s hard to predict how individuals, healthcare providers, and states would respond.”

Here are the key ways this bill would lead to more uninsured people.

Experts assert that cuts in federal funding for Medicaid will have significant consequences for many.

“No demographic is truly safe from a bill proposing to cut over $800 billion from Medicaid over the next decade, as states will need to adjust accordingly,” noted Allison Orris, senior fellow and director of Medicaid policy at the Center on Budget and Policy Priorities, a left-leaning think tank.

The House proposal’s most impactful measure would be new work requirements for states that expanded Medicaid under the Affordable Care Act, according to Orris.

The work requirements would primarily impact those aged 19 to 64 without qualifying exemptions, requiring them to prove they worked or engaged in qualifying activities for at least 80 hours each month.

States will also have to confirm applicants meet these requirements for consecutive months before coverage can begin, along with conducting reviews at least twice a year to ensure continuous compliance for those already enrolled.

During a recent interview on NBC’s “Meet the Press,” House Speaker Mike Johnson stated that “4.8 million individuals will not lose Medicaid coverage unless they opt to,” insisting the work requirements are not overly burdensome.

However, the CBO anticipates that these work requirements could lead to 5.2 million adults losing federal Medicaid coverage. Even if some find alternative insurance, the CBO projects an increase of 4.8 million people lacking health insurance as a result.

These estimates might be conservative, as they don’t account for individuals who qualify but fail to report their work hours accurately or don’t submit the necessary paperwork for exemptions, according to KFF’s Burns.

In total, 10.3 million individuals might lose Medicaid, leading to 7.8 million people without any health insurance, Burns explained.

While states have generated revenues for Medicaid through health care provider taxes, the House proposal would eliminate this funding source, according to Orris.

This reduction in revenue and federal support will force states to either cut coverage or reduce budget allocations elsewhere in order to keep their Medicaid programs sustainable, Orris remarked.

For instance, states may need to reduce funding for home- and community-based services to maintain mandatory coverage for inpatient and outpatient hospital services, she added.

Additionally, the House proposal would postpone until 2035 two Biden-era rules aimed at simplifying Medicaid enrollment and renewal for seniors and individuals with disabilities, according to Burns.

States will also see a decrease in their federal matching rate for Medicaid costs should they provide coverage for undocumented immigrants, Burns noted.

Over 24 million individuals have health insurance via the Affordable Care Act (ACA) marketplaces.

These marketplaces are crucial for those who lack access to job-based health insurance, including self-employed individuals, low-income workers, and older adults who haven’t yet qualified for Medicare, according to research from the Center on Budget and Policy Priorities (CBPP).

According to Drew Altman, president and CEO of KFF, new House legislation could significantly lower ACA enrollment—and thus the number of insured individuals—due to a series of smaller changes rather than a single major initiative.

Altman noted, “Many of these changes are complex and somewhat technical, but they are still impactful.”

ACA enrollment is currently at a record high. Since 2020, it has more than doubled, primarily due to the enhanced insurance subsidies introduced by Democrats in the American Rescue Plan Act of 2021 and later extended through 2025 by the Inflation Reduction Act.

These subsidies, called “premium tax credits,” lower consumers’ monthly premium costs. Households can either claim them at tax time or receive them upfront through reduced premiums.

Congress also broadened the eligibility criteria for subsidies, allowing more middle-income families to qualify and lowering the maximum annual contribution they need to make towards premiums, experts indicated.

The enhanced subsidies have lowered premiums for households by $705, or 44%, bringing the average annual premium down to $888 from $1,593 in 2024, according to KFF.

However, the House Republican legislation does not extend these enhanced subsidies, meaning they will end this year.

If the expanded premium tax credits expire, around 4.2 million people could be uninsured by 2034, as predicted by the Congressional Budget Office.

John Graves, a professor of health policy and medicine at Vanderbilt University School of Medicine, stated, “People may choose not to get coverage simply because they can’t afford it.”

For others who stay in a marketplace plan, costs will rise significantly: a typical family of four earning $65,000 could see their annual costs increase by $2,400 without the enhanced premium tax credit, as estimated by CBPP.

The Congressional Budget Office predicts that over 3 million people could lose their ACA coverage due to other changes in the House legislation.

Some significant changes involve alterations to eligibility criteria, according to Kent Smetters, a professor of business economics and public policy at the University of Pennsylvania’s Wharton School.

For instance, the bill shortens the annual open enrollment period by about a month, moving it from January 15 to December 15 in most states.

It also ends the practice of automatic re-enrollment in health insurance, which has been used by over half of individuals who renewed their coverage in 2025; instead, all enrollees will need to take action each year to maintain their insurance, according to CBPP.

The legislation would also prevent households from receiving subsidies or cost-sharing reductions until they confirm their eligibility details, such as income, immigration status, health coverage status, and place of residence, as noted by KFF.

Graves compares adding administrative hurdles for health plans to driving a cart of apples down a bumpy road, stating, “The bumpier you make the road, the more apples will fall off the cart.”

Another important change involves eliminating repayment caps for premium subsidies.

Households receiving federal subsidies must estimate their annual income, which determines their total premium tax credit. If their actual earnings exceed this estimate, they must reimburse any excess subsidies during tax season.

While current law caps repayment amounts for many households, the House bill would require all premium tax credit recipients to return any excess funds, regardless of their income level, according to KFF.

Though this requirement may seem fair, KFF’s Altman argues it is unrealistic and potentially “cruel.” He explained, “For low-income individuals, income can fluctuate, and many Marketplace users have hourly jobs, operate businesses, or juggle multiple jobs, making it hard to accurately predict their income for the coming year.”

The House bill also limits access to marketplace insurance for certain legal immigrant groups, according to experts.

Effective January 1, 2027, many legally present immigrants, including refugees, asylees, and those with Temporary Protected Status, would be ineligible for subsidized insurance on ACA exchanges, as stated by KFF.

Moreover, the bill would prohibit Deferred Action for Childhood Arrivals (DACA) recipients from purchasing insurance through ACA exchanges across all states.

DACA recipients, often referred to as “Dreamers,” currently qualify as “lawfully present” and can enroll in subsidized health coverage in 31 states and the District of Columbia.