Speaker McCarthy and congressional Republicans have committed to balance the budget while adding $3 trillion or more to the deficit through tax cuts skewed to the wealthy and large corporations. As a matter of simple math, that requires trillions in program cuts. Congressional Republicans have yet to disclose to the American people where these cuts will come from. But past Republican legislation, budgets, and litigation, along with recent statements, proposals, and budgetplans, provide clear evidence that health care will be on the chopping block for severe cuts.
Virtually every Republican budget or fiscal plan over the last decade has included repeal of the Affordable Care Act (ACA) and deep cuts to Medicaid. That would mean: higher health care costs for tens of millions of Americans; ending critical protections for people with pre-existing conditions; millions of people losing health coverage and care; and threats to health care for seniors and people with disabilities, including growing home care waiting lists and worse nursing home care.
The American people deserve to see congressional Republicans’ full and detailed budget plan, including what it cuts from the ACA and Medicaid, Social Security and Medicare, and other critical programs, and should have the chance to compare it with the President’s budget plan, which he will release March 9.
If Republicans are successful in repealing the Affordable Care Act and making deep cuts to Medicaid:
Millions of Americans Will Have Higher Health Care Costs
More than 100 million people with pre-existing health conditions could lose critical protections. Before the ACA, more than 100 million Americans with pre-existing health conditions could have been denied coverage or charged more if they tried to buy individual market health insurance. Republican repeal proposals either eliminate these protections outright or find other ways to gut them.
Up to 24 million people could lose protection against catastrophic medical bills. Before the ACA, insurance plans were not required to limit enrollees’ total costs, and almost one in five people with employer coverage had no limit on out-of-pocket costs, meaning they were exposed to tens of thousands of dollars in medical bills if they became seriously ill.
Tens of millions of people could be at risk of lifetime benefit caps. Prior to the ACA, 105 million Americans, mostly people with employer coverage, had a lifetime limit on their health insurance benefits, and every year up to 20,000 people hit that cap and saw their benefits exhausted just when they needed them most.
Millions of people could lose free preventive care. The ACA requires private health insurers to cover preventive services, like cancer screenings, cholesterol tests, annual check-ups, and contraceptive services, at no cost. Before these requirements were in place, millions of Americans with health insurance faced cost sharing – sometimes high costs – for these services, which is part of why the ACA resulted in increased use of critical preventive care.
Over $1,000 average increase in medical debt for millions covered through Medicaid expansion. Repealing the ACA, in particular the expansion of Medicaid to low-income adults, would reverse major gains in financial security. Within the first two years of the ACA’s expansion of Medicaid, medical debt sent to collection agencies dropped by $3.4 billion, and there were 50,000 fewer medical bankruptcies. Among people gaining coverage through expansion, medical debt fell by an average of over $1,000. Expansion states also saw significant drops in evictions compared to non-expansion states.
Tens of millions of people could see their prescription drug coverage scaled back. Prescription drug coverage is an optional benefit under Medicaid. If states faced large cuts to their federal Medicaid funding, millions of Medicaid enrollees could see their coverage scaled back or have a harder time getting their prescriptions because of extra red tape.
Millions of Americans Will Lose Their Health Insurance
40 million people’s health insurance coverage would be at risk. Over 16 million people have signed up for ACA marketplace coverage for 2023, over 22 million people are enrolled in Medicaid expansion coverage available due to the ACA, and another 1 million people have coverage through the ACA’s Basic Health Program. The total number of people with some form of ACA coverage has risen significantly since 2017, when the Congressional Budget Office estimated the House-passed repeal bill would grow the ranks of the uninsured by 23 million.
An additional 69 million people with Medicaid could lose critical services, or could even lose coverage altogether. Slashing federal funding for Medicaid would force states to make Medicaid eligibility changes that would make it harder to qualify for and enroll in Medicaid coverage. States would also likely consider capping or limiting enrollment, cut critical services, and cut payments rates, making it harder for people with Medicaid to access care.
Thousands more preventable deaths each year. The ACA Medicaid expansion is preventing thousands of premature deaths among older adults each year, research finds, likely because it improves access to care, including medications to control chronic conditions and preventive care such as cancer screenings. ACA marketplace coverage also prevents premature deaths.
Worse Care for Seniors and People With Disabilities
Over 7 million seniors and people with disabilities could receive worse home care, with ballooning wait lists for those still in need. The number of people on home care wait lists has dropped by 20 percent since 2018. This progress would likely be reversed under a block grant or per-capita cap because there would be fewer dollars available for home care services, an optional benefit in Medicaid. Faced with large federal funding cuts, states would almost certainly ration care. That would likely mean wait lists for home care in the 13 states and DC that don’t currently have them, and skyrocketing wait lists in 37 states that do.
Hundreds of thousands of nursing home residents would be at risk of lower quality of care. Over 60 percent of nursing home residents are covered by Medicaid. With large cuts in federal funding, states would be forced to cut nursing home rates to manage their costs, as many states have done during recessions. Research shows that when nursing homes are paid less, residents get worse care.
Millions of People Will Lose Access to Opioid Treatment and Mental Health Care
Millions of people could lose access to substance use treatment or mental health care. Across the country, the ACA, especially its expansion of Medicaid, has dramatically expanded access to opioid treatment and other substance use disorder care, including increases in medication assisted treatment prescriptions for opioid and other substance use treatment and improved access to mental health care.
34 million children at risk of losing guaranteed access to mental health care. Past Republican plans proposed ending Medicaid’s guarantee of comprehensive health coverage for children. This would jeopardize children’s access to mental health care at a critical point in efforts to address the burgeoning youth mental health crisis. It would also cause children to go without other services, like annual check-ups and speech and physical therapy. And Republican proposals could endanger schools’ ability to bill Medicaid for mental health care, speech therapy, or physical therapy for students.
Rural Hospitals Would Be Forced to Close
More of the over 500 rural hospitals at risk of closure could close. The ACA, especially its expansion of Medicaid, helped cut hospital uncompensated care by about $12 billion, helping hospitals, especially rural hospitals, stay afloat. Between 2010 and 2021, nearly three-fourths of rural hospital closures were in states that have not adopted Medicaid expansion, with research finding that expansion disproportionately improved rural hospital margins and helped avert rural hospital closures. If the ACA is repealed, and millions lose coverage, closures among at-risk hospitals could increase significantly.
Separate from all these quantifiable harms, Republican ACA and Medicaid plans propose abrupt, unprecedented upheaval, with consequences for the entire health care system. In 2017, patient groups, physicians, hospitals, insurers, insurance regulators, health care experts, and governors from both parties all expressed alarm that ACA repeals could have far-reaching consequences for the stability of health insurance markets and availability of affordable coverage and care.
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