Republicans’ Medicaid and ACA Changes Could Leave 8.6 Million Uninsured, Analysis Shows

A preliminary analysis by the Congressional Budget Office (CBO) estimates that a Republican legislative proposal to modify Medicaid and the Affordable Care Act would result in “at least 8.6 million” Americans losing health insurance coverage by 2034. However, many Democrats have cited a significantly higher figure of 13.7 million people—a number that misrepresents the direct impact of the legislation.

The discrepancy stems from Democrats combining the CBO’s estimate of insurance losses directly tied to the Republican bill with a separate issue—the scheduled expiration of expanded ACA tax credits at the end of this year. While Republicans generally oppose extending these credits, their expiration is not directly connected to the legislation currently before Congress.

During a May 13 mark-up session for the House Committee on Energy and Commerce’s reconciliation text, several Democratic lawmakers repeatedly referenced the 13.7 million figure. Rep. Diana DeGette of Colorado claimed the Republican agenda “will kick at least 13.7 million people off of health care coverage according to the nonpartisan Congressional Budget Office.” Similarly, Rep. Alexandria Ocasio-Cortez of New York asserted that “13.7 million Americans will be cut off from their health care and made completely uninsurable” by the Republican bill.

Senate Minority Leader Chuck Schumer amplified this message during a press briefing, describing the proposal as “the largest cut to Medicaid in American history” and claiming “at least 14 million Americans would be ripped off of their health insurance under this proposal.”

The CBO’s analysis, however, tells a more nuanced story. In a May 11 memorandum addressed to ranking Democrats on three congressional committees, the agency provided its assessment of portions of the reconciliation recommendations released that day. These recommendations are part of an extensive budget bill Republicans aim to pass using the reconciliation process, which requires only majority support in the Senate.

According to the CBO, the legislation as proposed would reduce the number of people with health insurance by “at least 8.6 million in 2034.” This figure comprises 7.7 million people who would lose coverage due to Medicaid program changes and 900,000 who would lose coverage because of changes to ACA marketplace enrollment standards.

Separately, the CBO noted that the expiration of expanded premium tax credits—a policy change not included in the current legislation—would increase the uninsured population by an additional 4.2 million by 2034 compared to permanently extending those credits. Another 900,000 could lose coverage due to other Trump administration-proposed changes to ACA marketplace rules. Together, these figures total 13.7 million—the number Democrats have been citing.

The enhanced tax credits, which Democrats expanded in 2021 and extended for three years in 2022, have reduced premiums for beneficiaries, enabling more Americans to purchase insurance. Making these credits permanent would cost approximately $335 billion over a decade, according to CBO and Joint Committee on Taxation estimates.

While Republicans have generally opposed extending these credits, the party is not united on this issue. Politico recently reported that “a growing number of Republicans have warmed to the idea,” including Senators Lisa Murkowski of Alaska and Thom Tillis of North Carolina, as well as Representative David Valadao of California.

Republicans face what Politico called a “difficult choice” between spending significant money to extend subsidies associated with the ACA—a law many Republicans have historically opposed—or allowing them to expire and potentially facing voter backlash in an election year as out-of-pocket costs rise.

Senator Tillis has suggested addressing the ACA subsidy extension after completing work on the reconciliation bill, according to Axios.

The CBO noted that it has yet to analyze other provisions in the legislation that would likely “somewhat further increase” its estimate of coverage losses if the bill became law. However, the current analysis puts the number of Americans who would lose coverage directly because of the proposed legislation at 8.6 million, not the 13.7 million figure that Democrats have frequently cited.