Halving the ACA's progress toward universal health coverage
More than halving, actually
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.
Very broadly speaking, the ACA cut the nation’s uninsured rate almost in half, from 14.6% in 2013 to 7.9% in 2023, according to KFF’s analysis of the Census Bureau’s American Community Survey. Well, we’re a backlash nation! CBO envisions Republican actions increasing the uninsured population by about 60% in 10 years.
A few notes on CBO breakouts of the effects of various provisions in its letter to ranking members of the Senate Finance Committee (Sen Wyden), House Energy & Commerce Committee (Rep. Pallone) and House Ways & Means Committee (Rep. Neal).
Work requirements for the ACA Medicaid expansion population account for the single biggest increase in the uninsured — 5.2 million, out of an estimated 18.5 million Medicaid enrollees subject to the requirements.
Changes to marketplace subsidy eligibility for lawfully present immigrants are forecast to increase the ranks of the uninsured by 1.3 million, while a funding penalty for states that provide Medicaid-like coverage with no federal funding to certain categories of undocumented immigrants will trigger coverage losses of 1.4 million — almost all of them in California, which now offers coverage to undocumented residents in all age groups. Note that the Republican talking point that the bill doesn’t remove eligibility for anyone except “illegal” immigrants is false— its attack on immigrants is evenly split between the undocumented and the lawfully present.
The coverage losses among lawfully present noncitizens include 300,000 who lose coverage because of repeal of subsidy eligibility in the ACA marketplace for low-income qualified immigrants subject to the 5-year waiting period for Medicaid —stripping eligibility from those with income below 100% of the Federal Poverty Level. In 2025, 549,000 marketplace enrollees had income below 100% FPL. CBO’s estimate confirms that most of them were immigrants.
The bill’s repeal of eligibility for lawfully present noncitizens who are not “qualified immigrants” — that is, those Present Under Color of Law (PRUCOL) — will raise the uninsured population by 1 million, according to CBO. Here are the categories of immigrants who will lose marketplace eligibility:
Cruel and stupid, or stupid and cruel? You choose.
The bill also strips Medicare eligibility from PRUCOL residents who otherwise qualify — i.e., those who have legally worked for 10 years in the U.S. CBO does not specify how many in this situation will lose coverage — but based on an estimated $5.5 billion in “savings” over ten years attributed to this provision (4% of “savings” from the Ways & Means immigrant-bashing provisions), I’d guess it’s about 100,000.
Continuing, 6/5/25:
The bill restores direct funding for Cost Sharing Reduction (CSR) — though only for insurers that do not offer abortion coverage or that restrict it to cases where it’s necessary to save the mother’s life or in cases of rape or incest. CBO estimates that this provision will increase the ranks of the uninsured by 300,000 by ending “silver loading” for about three quarters of enrollees (the other quarter. Readers of this blog are almost certainly familiar with the CSR pricing issue and what “silver loading” is, but as briefly as possible, let’s review. This provision has multiple implications, so I’ll take the discussion out of bullet points.
First, I might as well borrow from myself a recent review of the facts/history, in which I considered how silver loading might mitigate the expiration of the enhanced subsidies established by ARPA:
Silver loading, Part I. In October 2017, Trump cut off federal reimbursement of insurers for providing the Cost Sharing Reduction (CSR) subsidies mandated by the ACA to low-income enrollees in silver plan. (His basis: while the ACA mandated this reimbursement, it left funding those reimbursements up to Congress, and Republican Congresses declined to do so. The Obama administration had found reimbursement funds in couch cushions.) CSR increases the value of a silver plan to a roughly platinum level for enrollees with income up to 200% FPL. The move had been anticipated, and most state regulators responded by allowing or encouraging insurers to price CSR directly into silver plans, since CSR is available only with silver plans. Since ACA income-adjusted premium subsidies are set to a silver benchmark, this “silver loading” led to sharp reductions in net-of-subsidy premiums for bronze and gold plans (and less often, for the one silver plan priced below the benchmark in each market). As a result, the Kaiser Family Foundation (KFF) calculated that beginning in 2018, most enrollees with income up to 150% FPL, and a good number with higher incomes, had access to $0 premium bronze plans.
Silver loading, Part II. As direct CSR reimbursement had been contested from the start, prior to Trump’s cutoff, analysts at CMS, the Urban Institute, and CBO had anticipated the effects of pricing CSR into silver premiums. All three analyses anticipated that gold plans would be priced below silver plans, because most silver plan enrollees have incomes qualifying for strong CSR, and silver plan enrollees on average therefore obtain higher actuarial value than gold plan enrollees. It mostly didn’t shake out that way, as insurers have strong incentives to underprice silver plans. In about fifteen states, however, varying by year, gold plans are available at premiums below benchmark silver, sometimes by regulatory or statutory requirement, and sometimes by insurer choice (usually of a dominant insurer). Most notably — and astonishingly — Texas enacted a law requiring marketplace insurers to price gold plans far below silver. That makes sense, since 75% of enrollees in Texas have income below 200% FPL, and the average actuarial value of a silver plan in the state is over 90%, compared to 80% for gold plans. In 2025, 1.4 million Texas enrollees chose gold plans.
The fund-CSR provision was added to the House bill at the last minute, and it’s a really cruel blow to affordability across income levels. At the low end, expiration of the ARPA subsidy boosts means that high-CSR silver coverage is no longer available for zero premium at incomes up to 150% FPL, but silver loading would made left bronze and sometimes gold plans available for zero premium. Most notably, in Texas, 2 million enrollees in 2025 with income under 138% FPL would probably have had access to free gold plans under the pre-ARPA subsidy scheme (requiring 2% of income for the benchmark silver plan). While low-income enrollees are much better off in high-CSR silver, for many, any premium is prohibitive, as much for administrative as for financial reasons (conversely, zero-premium plans did facilitate an outbreak of broker fraud). And at incomes above 200% FPL, silver loading has made gold coverage affordable in many states — and bronze coverage much cheaper than it would be with CSR not priced into silver plans.
In a bizarre twist, withholding CSR reimbursement from states that allow insurers to fully cover abortion appears to have been conceived of as a penalty, whereas in reality it’s a boon, providing a major boost to premium subsidies entirely at federal expense, lowering costs for about 40% of enrollees nationally, by Stan Dorn’s estimate. I suspect that if this provision survives, rulemaking by Peter Nelson’s CMS will bar silver loading, requiring CSR to be priced evenly into plans at all medal levels.
Consider that Texas could preserve its maximized silver loading bounty by…allowing or mandating abortion coverage. Cruel joke. In fact, the lead sponsor of the silver loading bill in the Texas, physician Tom Oliverson, also sponsored bills to ban abortion.
As Texas is not going to mandate abortion coverage in it marketplace, here (via Charles Gaba) are the states that will benefit from the abortion “penalty” if this provision survives as is and silver loading is not banned administratively:
California
Colorado
Illinois
Maine
Maryland
Massachusetts
Minnesota
New Jersey
New York
Oregon
Washington
Vermont
CBO’s estimate that the bill’s changes to the ACA marketplace will reduce gross (pre-subsidy) benchmark premiums by 12.4% is probably due to funding CSR. As David Anderson of the University of South Carolina has found, lowering benchmark premiums makes coverage considerably more expensive for subsidized enrollees, and subsidies shrink with premiums, and price spreads between the benchmark plan and cheaper plans also shrink. Then again, expiration of the ARPA subsidy boosts will also greatly increase the number of unsubsidized enrollees, and reduced gross premiums do benefit unsubsidized enrollees.
As a final note, estimates of increases in the uninsured population generally come in at about two-thirds of estimates of the number of people losing a particular type of subsidized coverage. In a preliminary estimate, CBO pegged losses reductions in Medicaid enrollment and enrollment in state Medicaid-like programs for the undocumented at 11.7 million, leading to a net increase in the uninsured of 7.6 million. As for the marketplace, an Urban Institute analysis found that the enhanced subsidies boosted enrollment by 7.2 million in 2025 and reduced the uninsured population by 4 million. Those ratios suggest that an increase in the uninsured population of 16 million means that about 26 million will lose the coverage they have. That suggests marketplace enrollment dropping to about 10-11 million — roughly where it was in the first Trump administration before the pandemic provided a boost in OEP for 2021. Such a drop is not implausible, as the regulations proposed by CMS this spring and codified in the House bill erect more barriers and financial risk than regulations in the Trump 1.0 years — and Trump effectively established silver loading in October 2017.
Unbearable!