As the House-passed One Big Beautiful Bill Act moves to the Senate, we are inches away from undoing fifteen years of progress made possible by the Affordable Care Act (ACA). Republicans in Congress are inexplicably focused on policies that would make health care more complicated and expensive for tens of millions of hardworking, low- and middle-income Americans, children, and seniors to pay for trillions of dollars in tax breaks for corporations and the wealthy. New analysis from the nonpartisan Congressional Budget Office (CBO) projects 16 million people would lose health coverage due to the one-trillion dollar, ten-year budget cuts to health spending. These cuts are as deep as those in the ACA repeal bills proposed by the Republican Congress and President Trump in 2017.
There are alternatives, such as increasing the income tax rate by a little over 2.5 percent for the top tax filers, and there is time: Americans and their representatives in Congress should reject legislation that worsens the nation’s health coverage and care, as they did in 2017.
The Landscape That the House Bill Would Disrupt
By the end of the Biden–Harris administration, it had helped achieve the lowest uninsured rate in the nation’s history, lowered drug costs for those enrolled in Medicare, and established stronger standards for all insurance coverage.
We should know. From January 2021 to 2025, we were accountable for this work. We were, respectively, the administrator for the Centers for Medicare & Medicaid Services (CMS), former CMS senior advisor for Medicaid, and former director of the CMS Center for Consumer Information and Insurance Oversight. We started our jobs in the depths of the COVID-19 pandemic and experienced firsthand the value of improving eligibility processes for Medicaid enrollees and ACA marketplace consumers.
The hard work required to keep Americans covered was clear in 2023, when COVID-19 emergency protocols, including continuous coverage, ended and we resumed renewing coverage for everyone currently enrolled in Medicaid. We worked collaboratively across states, health plans, advocates, and CMS to reduce unnecessary paperwork and keep eligible people enrolled. And we succeeded: by streamlining eligibility and enrollment processes and modernizing states’ systems, we cut down on unnecessary and burdensome paperwork and made it easier for eligible people to enroll and keep their coverage.
We also simplified Medicaid and marketplace coordination of coverage. This included improving communication and data quality between both programs’ enrollment systems, smoothing transitions to the marketplace after some enrollees lost their Medicaid coverage. Combined with the increased affordability through enhanced marketplace premium tax credits, this led to record enrollment in coverage, and a drop in the uninsured. These changes have been especially meaningful to many middle-class families, particularly small business owners and workers who are typically the people who buy ACA marketplace coverage at higher income levels.
Adding Red Tape to Health Care Processes Would Cause Massive Loss of Coverage
Our nation’s focus at this time should be on building on these gains and pushing for more: better access to health care for people, particularly in rural areas; more support for our nation’s baby boomers as they age; lower prescription drug costs for everyone; and making our too complicated health care system less so. We spent every day working to make health care less expensive and making the system easier to navigate, but one thing is clear: for far too many Americans, health care remains too expensive and too difficult to access. We should be pushing for more simplicity. Instead, this bill would repeal almost all of these changes that we put in place and would add red tape processes that would end up denying people coverage and care.
We have all experienced painful red tape when dealing with insurance companies—whether sitting on hold to confirm a service is covered, or helping our elderly parents choose from a dizzying range of health plans. The anger that patients, doctors, and nurses across this nation feel about red-tape-induced delays in care is palpable—we heard about this on a bipartisan basis throughout our tenures. But when red tape prevents an eligible person from enrolling in coverage or staying covered, it can be deadly—over 51,000 people could lose their life as a result of this bill
The House-passed bill would cut around $1 trillion from Medicaid and private insurance through the ACA marketplaces. Proponents of the bill say that eligible people are not going to lose benefits, with savings coming from eliminating waste, fraud, and abuse. The numbers don’t bear that out. Less than 4 percent of the proposed Medicaid cuts come from addressing waste, fraud, and abuse. As a result of the other cuts, around 16 million people would lose coverage across programs, an increase of 50 percent in the uninsured. The bill is using extreme bureaucratic changes to inequitably, subversively, and undemocratically reduce eligibility.
Anyone, Including People with Disabilities and Children, Could Lose Their Medicaid Coverage from Excessive, New Paperwork Requirements
The primary way the bill would reduce Medicaid spending is through new, burdensome paperwork requirements outlined in the bill, such as work reporting and more frequent eligibility checks. It would also make it harder for low-income seniors to get help with their Medicare bills, children to get coverage quickly, and people with mild disabilities to stay covered. There is no question that changes are designed to make it harder for eligible people to stay covered.
Nearly all adults with Medicaid coverage are already working (64 percent of enrollees ages 19–64), or are exempt from work requirements because they are caregivers (12 percent), are ill or disabled (10 percent), or are in school (6 percent). However, many of these people would lose coverage as a result of the work requirement—even though they are already working or are eligible for an exemption. In 2018, research shows that about one in four Medicaid enrollees in Arkansas lost coverage in the first seven months—about 18,000 people—even though only 4 percent of Medicaid enrollees were not working, in school, or otherwise exempted. As CBO bluntly stated in its analysis, “Few of those disenrolled from Medicaid because of the policy would have access to and enroll in employment-based coverage and none would be eligible for the premium tax credit.”
That’s what makes these policies so dangerous. People who are in the midst of difficulty—those who are newly diagnosed with multiple sclerosis or cancer—now have to prove they are exempt from work requirements, or they lose their coverage. Parents losing eligibility can inadvertently result in children losing their coverage too (as high as 1.5 million children). And if an employer scales back their employees’ hours or makes cuts because of an economic downturn, employees will have to worry about keeping their health care coverage at the same time they are trying to keep their children fed. This red tape hurts people and causes waste; Michigan and Georgia spent tens of millions of dollars implementing these requirements.
The Bill Would Block the Marketplace from Using Enrollment Best Practices
The House-passed bill would also add new, excessive paperwork for those enrolling in the ACA marketplaces, either through Healthcare.gov or their state’s marketplace, such as Kentucky’s Kynect or Your Health Idaho. The bill would end auto-enrollment—a standard industry practice for Medicare, employer-sponsored insurance, and car insurance—and put in place strict verification requirements that place a larger burden on consumers to provide documentation or otherwise pay the full cost of premiums.
Many Americans enroll in marketplace coverage after experiencing a life change, such as losing a job, moving, or having a baby. The new verification requirements would only add further strain to an already stressful situation for these consumers. And, if a person loses their Medicaid coverage for procedural reasons—like many would as a result of work requirements—the bill would exclude them from eligibility for premium tax credits which would make coverage unaffordable to most.
Implementation Would Be Costly and Complex
We know firsthand the administrative nightmare it would be to implement these massive changes to program operations at both the state and federal level. Implementing these changes would require new business processes, large new contracts, updated technology, and new systems to handle the different verification needs. This means that call centers would be busier, wait times for accessing the navigators, agents, and brokers that assist with coverage applications would be much longer, and consumers would be left confused, without help, and potentially without coverage.
For example, CMS currently estimates that the costs to administer the new income verifications alone at both federal and state marketplaces could amount to $1.7 billion—a number that could be higher now that CMS has slashed funding for marketplace navigators that help people resolve verification and application issues from $98 million to $10 million. States running their own marketplaces will be especially hard-pressed to overhaul operating systems, as many of these changes need to be implemented in six months time to meet open enrollment deadlines. Both state and federal governments could not implement these changes efficiently since they seem designed to make enrollment hard.
Implementing Medicaid work requirements alone would also cost taxpayers hundreds of millions of dollars. Georgia’s work requirement cost Medicaid nearly $100 million dollars to implement—and only 7,400 of the 345,000 people the state estimated would be eligible were able to navigate the red tape to get health coverage.
Surprise Bills: Owing Thousands of Dollars More for Health Care
The House-passed bill also produces “savings” by shifting costs to people. In Medicaid, it would require states to impose cost sharing for every service used by certain enrollees. Some have rightly called this a “sick tax.”
The bill also includes several seemingly technical changes that would devalue tax credit plans, change how co-pays are paid for by the government, increase premiums and out-of-pocket costs by thousands, and remove the limit on how much tax credit recipients would owe at tax time. Someone with marketplace coverage might be able to absorb the costs of one of these changes, but taken together, they would mean thousands of dollars of costs to people who earn middle-class incomes in the country.
Imagine your friend opening their own business and enrolling in a health care plan through healthcare.gov. If this bill becomes law, your friend may lose a tax credit and face a thousand dollars more in unexpected taxes because their business earned more than expected, making it difficult to pay rent or the electricity bill that month. Or imagine your 26-year-old child aging off of your insurance and finding out, thanks to this bill, premiums are $500 to $1,000 more a year than expected. When you’re young and building up your finances, this could be detrimental to your financial stability. These are the types of policies that keep people from starting new businesses if they have health needs, deciding not to buy coverage hoping to stay healthy, or if they do purchase it, facing serious financial jeopardy. Lower enrollment and higher costs would also likely reduce competition in the ACA marketplace, leading to higher costs for even those who don’t receive tax credits.
This Is ACA Repeal by Another Name
We have described many problematic policies in this bill, yet there are even more provisions that would reduce coverage, increase costs on people, or shift costs to providers and states. Right before the passage of the ACA, one-third of the bankruptcies in our country were the result of medical debt. We don’t want to go back to a world where many people are choosing whether to put food on the table, pay for housing, or seek medical care—the costs are too great for our nation. If people don’t have stable health care coverage, they can’t start new businesses, they may delay having children, or they may be unable to go to work. Doctors, nurses and other care providers are struggling across this nation with paperwork demands, causing delays in care, provider burnout, and even some care providers leaving the profession altogether. Hospitals, too, would face higher uncompensated care costs from the millions of people becoming uninsured as a result of both the Medicaid and marketplace provisions in the bill, which would disproportionately harm rural hospitals. States and the federal government would spend billions of dollars implementing the requirements in this bill.
The One Big Beautiful Bill is ACA repeal by another name, and if the Senate passes the House bill, we would all face the repercussions. But hope is not lost—the House reconciliation bill is not yet law. And if people truly understand what is at stake with this bill, perhaps ACA repeal will be defeated again.
Tags: health coverage, health care costs, health care affordability
One Big Beautiful Bill Act Is a Repeal of the Affordable Care Act by Another Name
As the House-passed One Big Beautiful Bill Act moves to the Senate, we are inches away from undoing fifteen years of progress made possible by the Affordable Care Act (ACA). Republicans in Congress are inexplicably focused on policies that would make health care more complicated and expensive for tens of millions of hardworking, low- and middle-income Americans, children, and seniors to pay for trillions of dollars in tax breaks for corporations and the wealthy. New analysis from the nonpartisan Congressional Budget Office (CBO) projects 16 million people would lose health coverage due to the one-trillion dollar, ten-year budget cuts to health spending. These cuts are as deep as those in the ACA repeal bills proposed by the Republican Congress and President Trump in 2017.
There are alternatives, such as increasing the income tax rate by a little over 2.5 percent for the top tax filers, and there is time: Americans and their representatives in Congress should reject legislation that worsens the nation’s health coverage and care, as they did in 2017.
The Landscape That the House Bill Would Disrupt
By the end of the Biden–Harris administration, it had helped achieve the lowest uninsured rate in the nation’s history, lowered drug costs for those enrolled in Medicare, and established stronger standards for all insurance coverage.
We should know. From January 2021 to 2025, we were accountable for this work. We were, respectively, the administrator for the Centers for Medicare & Medicaid Services (CMS), former CMS senior advisor for Medicaid, and former director of the CMS Center for Consumer Information and Insurance Oversight. We started our jobs in the depths of the COVID-19 pandemic and experienced firsthand the value of improving eligibility processes for Medicaid enrollees and ACA marketplace consumers.
The hard work required to keep Americans covered was clear in 2023, when COVID-19 emergency protocols, including continuous coverage, ended and we resumed renewing coverage for everyone currently enrolled in Medicaid. We worked collaboratively across states, health plans, advocates, and CMS to reduce unnecessary paperwork and keep eligible people enrolled. And we succeeded: by streamlining eligibility and enrollment processes and modernizing states’ systems, we cut down on unnecessary and burdensome paperwork and made it easier for eligible people to enroll and keep their coverage.
We also simplified Medicaid and marketplace coordination of coverage. This included improving communication and data quality between both programs’ enrollment systems, smoothing transitions to the marketplace after some enrollees lost their Medicaid coverage. Combined with the increased affordability through enhanced marketplace premium tax credits, this led to record enrollment in coverage, and a drop in the uninsured. These changes have been especially meaningful to many middle-class families, particularly small business owners and workers who are typically the people who buy ACA marketplace coverage at higher income levels.
Adding Red Tape to Health Care Processes Would Cause Massive Loss of Coverage
Our nation’s focus at this time should be on building on these gains and pushing for more: better access to health care for people, particularly in rural areas; more support for our nation’s baby boomers as they age; lower prescription drug costs for everyone; and making our too complicated health care system less so. We spent every day working to make health care less expensive and making the system easier to navigate, but one thing is clear: for far too many Americans, health care remains too expensive and too difficult to access. We should be pushing for more simplicity. Instead, this bill would repeal almost all of these changes that we put in place and would add red tape processes that would end up denying people coverage and care.
We have all experienced painful red tape when dealing with insurance companies—whether sitting on hold to confirm a service is covered, or helping our elderly parents choose from a dizzying range of health plans. The anger that patients, doctors, and nurses across this nation feel about red-tape-induced delays in care is palpable—we heard about this on a bipartisan basis throughout our tenures. But when red tape prevents an eligible person from enrolling in coverage or staying covered, it can be deadly—over 51,000 people could lose their life as a result of this bill
The House-passed bill would cut around $1 trillion from Medicaid and private insurance through the ACA marketplaces. Proponents of the bill say that eligible people are not going to lose benefits, with savings coming from eliminating waste, fraud, and abuse. The numbers don’t bear that out. Less than 4 percent of the proposed Medicaid cuts come from addressing waste, fraud, and abuse. As a result of the other cuts, around 16 million people would lose coverage across programs, an increase of 50 percent in the uninsured. The bill is using extreme bureaucratic changes to inequitably, subversively, and undemocratically reduce eligibility.
Anyone, Including People with Disabilities and Children, Could Lose Their Medicaid Coverage from Excessive, New Paperwork Requirements
The primary way the bill would reduce Medicaid spending is through new, burdensome paperwork requirements outlined in the bill, such as work reporting and more frequent eligibility checks. It would also make it harder for low-income seniors to get help with their Medicare bills, children to get coverage quickly, and people with mild disabilities to stay covered. There is no question that changes are designed to make it harder for eligible people to stay covered.
Nearly all adults with Medicaid coverage are already working (64 percent of enrollees ages 19–64), or are exempt from work requirements because they are caregivers (12 percent), are ill or disabled (10 percent), or are in school (6 percent). However, many of these people would lose coverage as a result of the work requirement—even though they are already working or are eligible for an exemption. In 2018, research shows that about one in four Medicaid enrollees in Arkansas lost coverage in the first seven months—about 18,000 people—even though only 4 percent of Medicaid enrollees were not working, in school, or otherwise exempted. As CBO bluntly stated in its analysis, “Few of those disenrolled from Medicaid because of the policy would have access to and enroll in employment-based coverage and none would be eligible for the premium tax credit.”
That’s what makes these policies so dangerous. People who are in the midst of difficulty—those who are newly diagnosed with multiple sclerosis or cancer—now have to prove they are exempt from work requirements, or they lose their coverage. Parents losing eligibility can inadvertently result in children losing their coverage too (as high as 1.5 million children). And if an employer scales back their employees’ hours or makes cuts because of an economic downturn, employees will have to worry about keeping their health care coverage at the same time they are trying to keep their children fed. This red tape hurts people and causes waste; Michigan and Georgia spent tens of millions of dollars implementing these requirements.
The Bill Would Block the Marketplace from Using Enrollment Best Practices
The House-passed bill would also add new, excessive paperwork for those enrolling in the ACA marketplaces, either through Healthcare.gov or their state’s marketplace, such as Kentucky’s Kynect or Your Health Idaho. The bill would end auto-enrollment—a standard industry practice for Medicare, employer-sponsored insurance, and car insurance—and put in place strict verification requirements that place a larger burden on consumers to provide documentation or otherwise pay the full cost of premiums.
Many Americans enroll in marketplace coverage after experiencing a life change, such as losing a job, moving, or having a baby. The new verification requirements would only add further strain to an already stressful situation for these consumers. And, if a person loses their Medicaid coverage for procedural reasons—like many would as a result of work requirements—the bill would exclude them from eligibility for premium tax credits which would make coverage unaffordable to most.
Implementation Would Be Costly and Complex
We know firsthand the administrative nightmare it would be to implement these massive changes to program operations at both the state and federal level. Implementing these changes would require new business processes, large new contracts, updated technology, and new systems to handle the different verification needs. This means that call centers would be busier, wait times for accessing the navigators, agents, and brokers that assist with coverage applications would be much longer, and consumers would be left confused, without help, and potentially without coverage.
For example, CMS currently estimates that the costs to administer the new income verifications alone at both federal and state marketplaces could amount to $1.7 billion—a number that could be higher now that CMS has slashed funding for marketplace navigators that help people resolve verification and application issues from $98 million to $10 million. States running their own marketplaces will be especially hard-pressed to overhaul operating systems, as many of these changes need to be implemented in six months time to meet open enrollment deadlines. Both state and federal governments could not implement these changes efficiently since they seem designed to make enrollment hard.
Implementing Medicaid work requirements alone would also cost taxpayers hundreds of millions of dollars. Georgia’s work requirement cost Medicaid nearly $100 million dollars to implement—and only 7,400 of the 345,000 people the state estimated would be eligible were able to navigate the red tape to get health coverage.
Surprise Bills: Owing Thousands of Dollars More for Health Care
The House-passed bill also produces “savings” by shifting costs to people. In Medicaid, it would require states to impose cost sharing for every service used by certain enrollees. Some have rightly called this a “sick tax.”
The bill also includes several seemingly technical changes that would devalue tax credit plans, change how co-pays are paid for by the government, increase premiums and out-of-pocket costs by thousands, and remove the limit on how much tax credit recipients would owe at tax time. Someone with marketplace coverage might be able to absorb the costs of one of these changes, but taken together, they would mean thousands of dollars of costs to people who earn middle-class incomes in the country.
Imagine your friend opening their own business and enrolling in a health care plan through healthcare.gov. If this bill becomes law, your friend may lose a tax credit and face a thousand dollars more in unexpected taxes because their business earned more than expected, making it difficult to pay rent or the electricity bill that month. Or imagine your 26-year-old child aging off of your insurance and finding out, thanks to this bill, premiums are $500 to $1,000 more a year than expected. When you’re young and building up your finances, this could be detrimental to your financial stability. These are the types of policies that keep people from starting new businesses if they have health needs, deciding not to buy coverage hoping to stay healthy, or if they do purchase it, facing serious financial jeopardy. Lower enrollment and higher costs would also likely reduce competition in the ACA marketplace, leading to higher costs for even those who don’t receive tax credits.
This Is ACA Repeal by Another Name
We have described many problematic policies in this bill, yet there are even more provisions that would reduce coverage, increase costs on people, or shift costs to providers and states. Right before the passage of the ACA, one-third of the bankruptcies in our country were the result of medical debt. We don’t want to go back to a world where many people are choosing whether to put food on the table, pay for housing, or seek medical care—the costs are too great for our nation. If people don’t have stable health care coverage, they can’t start new businesses, they may delay having children, or they may be unable to go to work. Doctors, nurses and other care providers are struggling across this nation with paperwork demands, causing delays in care, provider burnout, and even some care providers leaving the profession altogether. Hospitals, too, would face higher uncompensated care costs from the millions of people becoming uninsured as a result of both the Medicaid and marketplace provisions in the bill, which would disproportionately harm rural hospitals. States and the federal government would spend billions of dollars implementing the requirements in this bill.
The One Big Beautiful Bill is ACA repeal by another name, and if the Senate passes the House bill, we would all face the repercussions. But hope is not lost—the House reconciliation bill is not yet law. And if people truly understand what is at stake with this bill, perhaps ACA repeal will be defeated again.
Tags: health coverage, health care costs, health care affordability