House Republicans Won’t Let Go of Repealing ACA; Decimating Its Medicaid Expansion Would Harm Millions of Parents, Children, Disabled People

The Affordable Care Act’s (ACA) Medicaid expansion provides high-quality, low-cost coverage to 20.3 million people with low incomes nationwide and saves lives. But House Republican leadership is targeting hundreds of billions of dollars in Medicaid cuts squarely at expansion, threatening health and financial security for millions of people.^[1] Eliminating Medicaid expansion was a key goal of the failed effort to repeal the ACA during President Trump’s first term, and House Energy and Commerce Republicans appear to be considering various ways to undermine the expansion when marking up their reconciliation legislation the week of May 5.

Health coverage through Medicaid expansion makes people healthier and more financially secure by improving their access to preventive and primary care, providing care for serious diseases, preventing premature deaths, reducing cases of catastrophic out-of-pocket medical costs, and helping them stay working, a large body of research shows.^[2] Taking coverage away from some or all of the 20 million people benefiting from expansion would roll back that progress in the 40 states and the District of Columbia that have expanded coverage. (See Appendix Table 1 for Medicaid expansion enrollment by state, Figure 1 for enrollment by congressional district.)

To name just a few harms of cutting expansion, a person who loses their coverage through Medicaid can’t get cancer treatment, an older and frail adult loses the home-based care they need to stay out of an institution, or a young adult can’t get insulin to control their diabetes. Also under threat are parents covered through Medicaid expansion, and by extension their children, who face harms associated with more household medical debt and financial insecurity, as well as skipped preventive care visits that are crucial to healthy growth and development.

Threats to Coverage and Funding Are Varied and Harmful

Medicaid and the expansion are even more popular today than they were in 2017, when expansion faced threats remarkably similar to the menu of options Republican policymakers are considering now.^[3] These policies didn’t advance during that repeal attempt and should be rejected again:

• Taking coverage away from Medicaid expansion enrollees who do not meet harsh work requirements. Even though most Medicaid enrollees work,^[4] this approach would put coverage at risk for 20.3 million people.^[5]Work requirements take coverage from people who get trapped by complex work-reporting and verification systems. That includes people who lose coverage even when they are supposed to be exempt (for instance, because they have a disability, have serious health conditions, or are a caregiver), and because of circumstances beyond their control, such as layoffs, job losses, and temporary reductions in their work hours. (See Figure 2.) Work requirements don’t result in more people working — the Congressional Budget Office concluded that under a work requirement, “the employment status of and hours worked by Medicaid recipients would be unchanged.”^[6]
• Cutting the Medicaid expansion matching rate, shifting significant costs to states. The federal government now pays 90 percent of the costs it takes to cover Medicaid enrollees who gained coverage through the expansion. If that matching rate is reduced, states’ costs will double or even quintuple.^[7] Some states have laws requiring them to automatically drop their expansion if this match lowers.^[8] In other states, it would cost more than $1 billion a year to keep coverage for people enrolled in the Medicaid expansion.^[9]In either case millions of people would likely lose coverage, whether because expansion is no longer in effect in their state or because it struggles to cover the added costs. The massive cost shift could lead some states to drop benefits or coverage, for expansion enrollees or for other groups states now choose to cover.
• Capping expansion Medicaid spending, which likewise would shift costs and threaten coverage. Republicans are reportedly considering capping per-person spending for Medicaid expansion enrollees in a bid to cut federal support for the Medicaid expansion. Today, states and the federal government share in costs of covering Medicaid services, and both share in the risk if health care costs rise; a per capita cap would limit federal spending to a rate well below anticipated growth in health care spending and force states to absorb the cost of any Medicaid spending beyond an artificially low cap.^[10] Depending on which proposal is selected, it is likely that a per capita cap on federal funding for the expansion group would shift between $72 billion and $190 billion in costs to states from 2026 to 2034, increasing state expansion costs by 41 to 108 percent and jeopardizing coverage for millions of people.^[11]
• More frequent eligibility checks, increasing waste and enrollment churn. Today, enrollees have to complete renewals once per year and report any changes that may affect eligibility in between renewals (and states independently check data sources to detect changes as well). Proposals to fully redetermine eligibility for Medicaid expansion enrollees twice a year, or even four times a year,^[12] would add excessive red tape for enrollees and for state agencies, which are likely to make far more mistakes with the sharp increase in workload. Experience shows that people who still meet eligibility criteria will lose coverage and “churn” on and off Medicaid, which not only leads to higher healthcare costs due to interruptions in access to medications and treatment, making conditions harder to treat, but also increases costs and burden for states.^[13] Contrary to some Republicans’ claims, more frequent renewals, and the resulting churn, would not address fraud^[14] and would actually increase waste, not reduce it.^[15]

The coordinated attack on Medicaid expansion funding, eligibility requirements, and eligibility procedures would eviscerate the Medicaid expansion; in some states coverage losses could be immediate, in others red tape barriers will decimate the expansion population over time, which will increase our nation’s uninsurance rate.

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Many Groups Benefit from Expansion, and None Would Be Unscathed by Cuts

Republicans are justifying these cuts by making false claims that Medicaid’s expansion to low-income adults takes care away from traditionally eligible groups like children, pregnant enrollees, older adults, and people with disabilities. In reality, expansion supports better outcomes for all groups,^[16] and any cuts targeting expansion pose a risk to people in all these groups. Health coverage is a matter of life and death, and people who get their health care from Medicaid, including through the expansion, may not have any other pathway to coverage.^[17] This is in large part because many low-paying employers do not offer health care.

Far from diverting coverage and resources from the groups Medicaid traditionally covers, Medicaid expansion drove coverage gains for millions of adults with low incomes who had no other coverage options before the ACA. That includes many people in these groups who didn’t previously qualify. And states that expanded Medicaid actually invest more per enrollee overall and in each eligibility group than non-expansion states.^[18]

Medicaid expansion has made affordable coverage a reality for a range of people with lower incomes. Among those Medicaid expansion has helped:

• Parents. Without expansion, the income limits to qualify for Medicaid as a parent are very low. Today, the median eligibility limit to qualify as a parent in non-expansion states is just 34 percent of the federal poverty level (about $9,061 a year for a family of three), and adults without children are generally not eligible, unless they qualify on the basis of unusually high medical need or a disability.^[19] Therefore, in non-expansion states most parents with incomes anywhere between their state’s low eligibility limit and 138 percent of poverty ($37,777 a year) don’t have access to Medicaid, and many are uninsured. In expansion states, however, parents and all other non-elderly adults are eligible for Medicaid if they have income up to 138 percent of poverty.
• Children. In most states Medicaid expansion drove coverage gains for parents, which also improved access to care and overall well-being for their children. When parents have health coverage, their children are more likely to be covered as well.^[20] Expansion has also been associated with an increased likelihood of children receiving annual preventive care visits, which are crucial for their healthy growth and development.^[21] And parents having health insurance helps protect the entire household from medical debt and bankruptcy due to medical expenses, supporting the financial security of the entire household.^[22] States that have expanded Medicaid have consistently had lower uninsured rates among children.^[23] And almost half of the nation’s uninsured children live in non-expansion states.^[24]
• People with disabilities and chronic conditions. Medicaid expansion has also increased coverage for people with disabilities, allowing many to qualify based on income rather than strict disability eligibility criteria. Nationwide, approximately two-thirds of non-elderly adult Medicaid enrollees with a disability do not receive Supplemental Security Income, which would qualify them for Medicaid on the basis of disability; instead, many of these adults are likely covered through Medicaid expansion.^[25] Similarly, KFF recently found that nearly half (44 percent) of expansion adults have at least one chronic condition, including physical and mental health conditions. And of Medicaid enrollees with at least one chronic condition, more than half (53 percent) are enrolled in the Medicaid expansion.^[26]
• Women. Women of reproductive age — those who are not yet able to qualify for Medicaid on the basis of being pregnant or having a child — have also gained a pathway to comprehensive, affordable coverage through the Medicaid expansion. KFF found that 38 percent of women aged 19-49 who are enrolled in Medicaid are enrolled in the expansion group.^[27] Having affordable, stable coverage before pregnancy helps improve the health of mothers and their babies.

• Older adults. Expansion covers more than 60 percent of Medicaid enrollees aged 50-64, before they are eligible for Medicare.^[28] Medicaid expansion has saved lives, especially among newly covered near-seniors who otherwise would not have access to affordable coverage. A study of 55- to 64-year-olds shortly after the expansion went into effect found that Medicaid expansion reduced annual mortality rates between 39 percent and 64 percent for older adults gaining coverage.^[29] Among people aged 50-59, more than 11,000 lives were saved between 2010 and 2022, a more recent study found in states that expanded.^[30]

  And while people 65 and older are not eligible for Medicaid expansion directly, they have also benefited from expansion. Data show that among adults aged 65 and over with limitations related to a chronic condition, those in expansion states are significantly more likely than those in non-expansion states to be covered by traditional Medicaid (alongside Medicare) and to have had a recent physician office visit.^[31]

• Veterans. Many veterans and their families receive health care from Medicaid. Because of restrictions on Veterans Affairs and TRICARE eligibility, many veterans and their families rely on Medicaid following separation from military service. Nearly 1.6 million veterans are enrolled in Medicaid,^[32] not only for routine and acute care services, but also for care for service-related conditions including mental health services and treatment for substance use disorder.

Eliminating Medicaid expansion was a key goal of Republicans’ failed effort to repeal the ACA eight years ago, and Congress should once again reject efforts to undermine it. People who need health care would lose their coverage or see it worsen, and that includes the parents, children, and people with disabilities that many policymakers say they want to protect.

Appendix