By Suzanne Wikle

The first year and a half of Trump’s second term and the 119th Congress makes it very clear that policymakers are waging a wholesale attack on people’s ability to afford health care – a basic human right that everyone should have. Republicans’ assault on health care goes far beyond the $1 trillion they cut from Medicaid and ACA last year as part of H.R.1, the Budget Reconciliation Act of 2025.

The Republican-led H.R.1 is estimated to cause nearly 17 million people to lose their health insurance in the next decade, in large part because of new Medicaid eligibility requirements forcing people to prove they are working, volunteering, or exempt from the requirements. Last week, the Centers for Medicare and Medicaid Services (CMS) released an interim final rule to states about implementation details. As pointed out by 48 patient advocacy groups, the guidance goes against promises made by Congressional Republicans and makes it harder for people who are “medically frail” to stay eligible for Medicaid.

Prior to the rule being published, states were under the impression from CMS that they would be able to use existing data to identify someone as medically frail (e.g., someone with a cancer diagnosis). Under the published rule, people will now have to prove that a medical condition “significantly impairs” their ability to work. This will be incredibly burdensome for individuals and increase the workload of state eligibility workers. The administration didn’t have to do this and could have made it easier for people with cancer diagnoses or other illnesses to remain eligible for Medicaid. But administration officials went out of their way to write the rules in a way that will cause more people to lose their health insurance.

States are starting to speak up about the cost to implement H.R.1’s Medicaid changes. In addition to taking health care away from millions of people, states are on the hook for tens of millions of dollars to change computer systems and hire new eligibility staff. The Trump Administration is adding to state budget woes by again going beyond what H.R.1 required in terms of financing changes related to State Directed Payments – a wonky but important way federal dollars flow to states to keep Medicaid programs afloat. H.R.1 cut these funds to states and then CMS released guidance last month that will triple the financing cuts that were included in the legislation. If this stands in the final guidance, state budgets will face even greater Medicaid cuts, which will lead to even more people losing health care.

To add to the devasting cuts in H.R.1, CMS issued a proposed rule for insurers in the 2027 Marketplace. Once again, CMS continued its assault on people by significantly changing the rules to favor insurers and harm people. The proposed rule allows insurers to require people to pay more out of their pocket with higher deductibles and cost-sharing. Moreover, the rule would allow insurers to offer “no network” plans – literally putting the responsibility on people to ask their doctors if they will accept their insurance plan’s reimbursement rate. This is nothing but a giveaway to insurance companies and will undoubtedly lead to people paying more, delaying or forgoing health care, and likely taking on more medical debt.

Congress’s willingness to let enhanced subsidies for Marketplace insurance expire at the end of 2025 led to 1.2 million fewer people with insurance so far, and even more with lower tier plans that require more out-of-pocket costs and may have fewer benefits or more restrictive medication coverage.  The recent actions by the Trump Administration will only add to the growing number of people who recently lost their health insurance.

The pattern is clear – at every opportunity and with every tool at its disposal, the Trump Administration is making it harder and more expensive for people to have health insurance and get the care they need. The full impact of H.R.1 and these proposed rules will take years to materialize, but there is no doubt that millions of people will lose their health insurance or have to pay more out of their pocket to use their insurance. It doesn’t have to be this way. We know that poverty a policy choice, but so is meeting people’s basic needs.

It’s clear that the current Congress and administration are intent on dismantling health care instead of solving the health care crisis in this country. CLASP will continue to work with partners to elevate the need for true solutions that live up to our belief that health care is a basic human right.