President Donald Trump has promised not to cut Medicaid many times over the past decade, including in the tax-and-spending legislative package he has made a top priority in his second administration.
But several provisions in the bill, which the House of Representatives passed in a largely party-line 215-214 vote in May 2025, could cause millions of Americans enrolled in Medicaid to lose their health insurance coverage, according to the nonpartisan Congressional Budget Office. Medicaid is funded jointly by the federal government and the states. The program provides nearly 80 million Americans, most of whom are low-income or have disabilities, with health insurance.
The legislation, which advances Trump’s agenda, faces a tough battle in the Senate despite the Republican Party majority in that chamber. Several GOP senators have either said they oppose it or have expressed strong reservations for a variety of reasons, including the trillions of dollars the package would add to the U.S. government’s debt.
As a scholar who researches access to health care, I am concerned about the possibility that millions of people will lose their health insurance coverage should this bill become law. In many cases, that could occur due to new bureaucratic obstacles the bill would introduce.
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Proposed policy changes and the uninsured
About 25.3 million Americans lacked insurance in 2023, down sharply from 46.5 million in 2010. Most of this 46% decline occurred because of the Affordable Care Act of 2010.
The Congressional Budget Office, a nonpartisan agency that provides evidence-supported information to Congress, estimates that 10.9 million Americans would lose their health insurance by 2034 if the House of Representatives’ version of that package were to become law.
Of these, as many as 7.8 million would lose access to Medicaid.
Another 2.1 million people who the CBO estimates would end up uninsured are Americans who today have coverage they bought in the marketplaces that the Affordable Care Act created.
In addition to the measures in the tax-and-spending bill, other changes are looming. These include the expiration of some ACA-related measures adopted in 2021 that Trump does not intend to renew, and new regulations. All told, the number of Americans losing their health insurance by 2034 could total 16 million, according to the CBO.
Other estimates suggest that the number of Americans losing their coverage could run even higher.
Obstructing Medicaid expansion
The House bill would reduce incentives the federal government provides states to expand their Medicaid programs as part of the ACA.
Eliminating these incentives would make it even less likely that Texas and the other nine states that still have not expanded Medicaid eligibility would do so in the future.
The bill would also make it harder for states to come up with their share of Medicaid funding by limiting “provider taxes.” These taxes are charged to hospitals, doctors and other medical providers. The revenue they raise help pay for the state’s share of Medicaid costs.
And the legislative package would also reduce federal funding to cover Medicaid costs in states that provide coverage to unauthorized immigrants using only their own funds. Threatened with billions in losses, the states that do this are unlikely to maintain these programs. In California alone, this would jeopardize the coverage of 1.6 million of its residents.
Losing Medicaid coverage may leave millions of low-income Americans without insurance coverage, with no affordable alternatives for health care.
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Making Medicaid enrollment more complicated
Other proposed changes in the House bill would indirectly cut Medicaid coverage by forcing people to deal with more red tape to get or keep it.
This would happen primarily through the introduction of “work requirements” for Medicaid coverage. When enrolled in the program, applicants who are between 19 and 64 years old would need to certify they are working at least 80 hours a month or spending that much time engaged in comparable activities, such as community service.
Work requirements specifically target people eligible for Medicaid through the Affordable Care Act’s expansion of the program. They tend to have slightly higher incomes than the other people eligible for this benefit.
Arkansas gave Medicaid work requirements a try during the first Trump administration. Researchers who studied what happened found that 1 in 4 of the Arkansans enrolled in Medicaid affected by the policy lost their health insurance coverage. They also found that in most cases, this occurred because of bureaucratic obstacles, and that the policy didn’t lead to more people getting jobs.
By some estimates, the work requirements provision alone would lead to close to 5 million people of the 7.8 million being denied Medicaid coverage.
At the same time, the bill would increase how often Medicaid beneficiaries have to reapply to the program to keep their coverage from once every 12 months to twice a year.
It also would delay or reverse several policies that made it easier for Americans to enroll in Medicaid and maintain their coverage. Many of those who aren’t kicked out would also face either new or higher co-payments for appointments and procedures – restricting their access to health care, even if they don’t wind up without insurance.
There is ample evidence that obstacles like these make it hard to remain enrolled in safety net programs. Historically, the people who are most likely to lose their benefits are low-income, people of color or immigrants who do not speak English well.
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Costlier Marketplace policies and more barriers
The bill would also affect the more than 24 million Americans who get health insurance through Affordable Care Act Marketplace plans.
Changes in the House version of the bill would make it harder to get this coverage. This includes reducing the time Americans have to enroll in plans and eliminating certain subsidies. It also makes the enrollment process more complicated.
Combined with other changes the Trump administration has made, experts expect Marketplace premiums to skyrocket.
The Congressional Budget Office expects more than 2 million beneficiaries to lose coverage due to these new policies.
More coverage losses possible
Americans buying their own insurance on the ACA marketplaces may also face higher premiums.
Increased subsidies in place since 2021 are set to expire at the end of the year. Combined with Trump regulatory decisions, this may lead to more than 5 million Americans losing coverage – whether or not the GOP’s tax-and-spending package is enacted.
The effects of the bill would also be compounded by further changes by individual states. This could include the introduction of monthly premiums that people with Medicaid coverage would have to pay, in Indiana and other states.
Some states may also reduce eligibility for certain groups or cover fewer services, as states seek to reduce their Medicaid costs.
And some states, including Iowa and Utah, are already pursuing work requirements on their own whether or not they become mandatory across the nation.
If fewer Americans have health insurance due to changes the Trump administration is making and the policies embedded in the pending tax-and-spending legislative package, the health of millions of people could get worse due to forgone care. And at the same time, their medical debts could grow larger.
