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You are here: Home / Anderson On Health Insurance / One Big Bad Bill and the ACA

One Big Bad Bill and the ACA

by | 40 Comments

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The bill that passed the House this morning (with all marginal seat Republicans voting for it) will lead to well over 10 million people directly losing health insurance coverage due to its provisions.  More will lose coverage due to inaction and there will be massive variation in coverage losses in Medicaid due to the degree of administrative competence and political give a damn at the state level. It is also a huge ACA cutter.

Before overnight amendments, coverage loss from marketplace policies accounted for about a quarter of coverage losses.

With ending silver loading, my guess is we get closer to a third?

And if you count the 4.2M losing coverage because of expiring enhanced subsidies, you start to approach halfsies.

[image or embed]

— Adrianna McIntyre (@adrianna.bsky.social) May 22, 2025 at 7:14 AM

The big new addition to the text last night for the ACA was the appropriation of funds to pay Cost Sharing Reduction subsidies which, since 2018 have been incorporated into Silver plan premiums. This would dramatically make the cheapest plans much more expensive for subsidized enrollees. Drake and Abraham illustrated this in 2019:

mean 2014‐2017 premium spreads allowed single enrollees at or below 149 percent of the FPL to purchase the lowest premium plan for zero dollars. After CSR cuts, mean premium spreads increased such that in 2018‐2019, enrollees at or below 208 percent of the FPL could purchase the lowest premium plan for zero dollars.

If signed into law, this will wreck the Texas ACA market as the state has aggressively silverloaded whic has dramatically increased the number of people covered (most of the gain, per my dissertation, is among folks with incomes over 200% FPL).

I will have more thoughts later (likely writing an academic commentary today fueled by a decade of knowledge, anger, and coffee).

Reader Interactions

40Comments

  1. 1.

    narya

    One thing I’d like to know, when you get a chance: they’re saying that there will be cuts to MediCARE as well. What form would that take? Higher premiums? Less coverage? I don’t know what can be cut.

  2. 2.

    David Anderson

    @narya: That is beyond my expertise.  From my understanding the increase in the deficit for non-emergency spending is triggering PAYGO/Sequester rules from 2011 which mandates offsetting cuts in both mandatory Medicare spending and discretionary spending.

    The size of those cuts will be determined by the CBO score of the bill.  Earlier in the week, the estimate was $500 billion + in Medicare cuts over a decade, but with the end of Silverloading as a pay-for AND speeding up work requirements, the deficit increase would be smaller as these are big new spending cuts so the Medicare cuts would be smaller.

    I think the cuts would be on provider payment.

  4. 4.

    artem1s

    Where’s the TeaParty now? Why aren’t they screaming at their reps 24/7/365 about keeping the government’s hands off their medicare/medicaid? I guess they all believe TCF is only cutting Obamacare.
    Morans.

  5. 5.

    chemiclord

    Just remember guys, Kamala Harris wasn’t good enough on the genocide occurring in a completely different country, so this simply had to happen.

    Stupid fuckin’ Dems.

  7. 7.

    artem1s

    @David Anderson:

    I assume basic coverage will be cut back to letting us die in an emergency room and pretty much nothing else.  That will save billions, right?

    Any word on whether they are trying to let insurance companies go back to denying care based on pre-existing conditions? IIRC denial of service is what the Federalist Society loved most about RMoneycare and removing that and the caps on coverage is what they hated most about Obamacare.

  8. 8.

    Elizabelle

    David:  maybe we should conduct protests with informative signs at Thom Tillis’s local offices.  He will be vulnerable.

    Different kind of meetup.  I am in Virginia, and would drive down for this.

  12. 12.

    Professor Bigfoot

    @Baud: More coffee, dawg. Even the short-tempered Professor detected that sarcasm.

    (of course, now I’m working on my second cuppa so I’m almost intelligible…)

  13. 13.

    Interesting Name Goes Here

    @chemiclord: I hope Progressives™ get to think good and hard about their life choices and how they got here every day for as many generations as it takes for them to be taken seriously once more, because they absolutely should not ever be taken seriously again after 2024.

  15. 15.

    Professor Bigfoot

    @Baud: My friend, you have my sympathies.

    The common cold has a misery/lethality ratio that’s near infinite; it won’t kill ya, but it’ll make you SO miserable… get better soon, mate!

  17. 17.

    Betsy

    I was just talking to my friend last evening about getting ACA coverage and how it works.  She is losing her job soonbecause of DOGE grant cuts to her institution.

    Thanks for the review, David.

    and thanks for nothing, Republican assholes

  18. 18.

    the pollyanna from hell

    @Baud: ​
     I try to never snark without obvious signals of absurdity, and I still get it wrong.

  20. 20.

    jonas

    Once again Republicans are betting everything on the idea that screwing over poor/working class people has no real political cost, whereas the donor class will reward them for preserving the tax cuts.

  21. 21.

    RaflW

    Cancelling cancer research, including some work that was near big breakthroughs. Throwing grandmas onto the street when Medicaid nursing homes go bust. Millions losing the affordability of Silver plans.

    It is not hyperbole to say that the Republican Party is pro-death

    I cannot really understand why. I guess people living lives that are short, brutish and hard will make staffing the minimum wage economy easier for the overlords? It’s a very dour, miserable and bleak future. I’m sure Zuckerberg et al imagine flying above it all in helicopters and such, hopping from gated retreat to tropical isle to Parisian cafe, but the misery will permeate and stink.

    I’m just agog at how awful the future looks under “Greatness”.

  22. 22.

    Steve LaBonne

    @jonas: When do they ever pay more of a political cost than being out of power for only a couple of years? And that’s why they just get worse and worse.

  23. 23.

    RaflW

    @artem1s: “Where’s the TeaParty now?” It’s been 16 years, so some of them are dead now. I remember back then the jokes about how many of ’em were in zippy chairs, but alas those decrepit old coots are probably mostly still here.

    Certainly the cretins with the money who astroturfed the damn thing are still here, and they’re finally getting the shitscape they crave.

  25. 25.

    Scout211

    @David Anderson: I think the cuts would be on provider payment.

    That’s what  KFF is reporting:

    One consequence of the reconciliation bill that is making its way to the House floor is more than $500 billion in Medicare cuts between 2026 and 2034. According to the Congressional Budget Office, the reconciliation bill reported out of the House Budget Committee would increase the deficit compared to current law by at least $2.3 trillion. If enacted into law in its current form, and Congress takes no further action, that increase in the deficit would trigger mandatory cuts, also known as sequestration, under the Statutory Pay-As-You-Go Act of 2010. Unlike Social Security and programs for low-income people, Medicare is not exempt from these cuts.

    Triggering Statutory PAYGO would mean an automatic 4% reduction to most Medicare spending. That includes payments to hospitals, physicians and health care providers, Medicare Advantage plans, and standalone prescription drug plans. The cuts to hospitals are on top of the effects of Medicaid changes included in the legislation. Some spending to support low-income beneficiaries is exempt, but most Medicare spending is not.

    The purpose of Statutory PAYGO was to impose some budget discipline. However, the across-the-board cuts triggered by the law have never been allowed to go into effect because Congress has either excluded those effects from the “scorecard” as part of the underlying legislation or later acted to exclude or delay the effects. For example, neither the 2017 Tax Cuts and Jobs Act nor 2021 American Rescue Plan resulted in automatic cuts despite large increases in the federal deficit.

    Congress could choose to take action before the end of the year to block implementation of the cuts as it has done in the past. Unlike the reconciliation bill, excluding the effects of legislation from the PAYGO scorecard requires 60 votes, rather than a simple majority in the Senate, which is a higher hurdle.

  26. 26.

    PatD

    @chemiclord: This wasn’t why Harris lost and I think that’s fairly established by now. Millions didn’t sit out from 2020 due to Gaza, a fringe issue at best.

  27. 27.

    jonas

    @Steve LaBonne: Yep. Blow everything up and if voters toss you out, wait for them to just blame Democrats for not fixing everything immediately and then swoop back into power to fuck everything up even worse. Wash, rinse, repeat.

    As long as voters have the political awareness and memory of sea slugs, this isn’t going to stop.

  28. 28.

    gene108

    @artem1s:

    IIRC denial of service is what the Federalist Society loved most about RMoneycare and removing that and the caps on coverage is what they hated most about Obamacare.

    Between RFK, Jr. and MAHA, as well as the Christian conservatives and their belief in that some people deserve support and others don’t, I think the Republican party has an implicit eugenics agenda where vulnerable people are left to die because they lack access to healthcare and housing.

    Also, all this suffering is for millionaires billionaires to get tax cuts. Yet some people wonder why Luigi became a folk hero to many.

  29. 29.

    jonas

    @chemiclord: The Gaza war may have affected turnout and votes in Michigan, but I don’t think it was a major factor in the election overall. Harris lost because a bunch of voters in swing states who had voted for Biden in 2020 were pissed at the cost of eggs and rent and had a bad case of political amnesia, so went for Trump (or stayed home). It was really just that stupid.

  30. 30.

    gene108

    @Steve LaBonne:

    When do they ever pay more of a political cost than being out of power for only a couple of years? And that’s why they just get worse and worse.

    @jonas:

    As long as voters have the political awareness and memory of sea slugs, this isn’t going to stop.

    The power of right-wing propaganda in this country to warp reality is the biggest problem we face. I think it was the deciding factor in 2024.

    Outside of political junkies like us, it’s hard for normies to cut through the right-wing BS. The MSM has been influenced by right-wing propaganda for over 30 years, they don’t help offset it.

    I do not know how to counter it.

    The problem Trump, Fox News, Matt Walsh, etc. has now is the propaganda is running into hard reality like egg prices, grocery bills, and job losses that can’t be as effectively BS’ed away. When they’re out of power or campaigning there aren’t as much hard reality for people to compare it against. All the counter arguments against why tariffs will suck can be brushed aside with “that’s just your opinion” or outright lies like “other countries pay tariffs”.

  31. 31.

    Matt McIrvin

    @RaflW: The Silent Generation and older Boomers who were the Fox News geezer core of the right are dying off, and younger Boomers are actually a bit more liberal: you can see them turning out for street protests now! But the white GenXers who are now entering prime voting age are as reactionary as the dying geezers, and there’s a new population of deeply misogynistic, racist young white men taking up the torch. So demographics alone won’t save us, at least in the near term.

  32. 32.

    catclub

    @Professor Bigfoot: ​
     

    The common cold has a misery/lethality ratio that’s near infinite

    Tell that to an 89 year old with copd. My value for infinity starts at something higher than 10,000

  35. 35.

    catclub

    @gene108: have the political awareness and memory of sea slugs,

     

    I prefer the memory of a mayfly analogy.

    I can imagine sea slugs being pretty stubborn.

  37. 37.

    RaflW

    @Matt McIrvin: The gender split on Xers is pretty big. As one of the older X gen ppl, I’m very disappointed that all these f-ing Alex P Keatons grew up to be as terrible as they were when I was in college with them.

  38. 38.

    Sister Golden Bear

    David, while it’s a niche issue compared to the overall devastation of the proposed Medicaid/Medicare cuts, House Republicans changed language in the dead of night to ban it covering transgender healthcare—including hormones—for not just trans youth, which would’ve been bad enough, but for all trans people, including adults.

    The policy change could have devastating consequences for transgender people across the United States and is likely to clash with state laws that mandate insurance coverage for gender-affirming care. According to the UCLA Williams Institute, more than 152,000 transgender Americans currently rely on Medicaid for their care. Stripping that coverage would make surgeries cost-prohibitive for many, with procedures often running into the tens of thousands of dollars. Even routine hormone therapy and necessary bloodwork could become financially out of reach. For countless trans adults, this would mean either turning to unsafe alternative care or being forcibly taken off treatment—a process known as medical detransition. The effects can be severe, particularly for those who’ve already undergone surgery and require ongoing hormone supplementation, putting both mental and physical health at serious risk.

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