By Suzanne Wikle

In 2017, Republicans were boldly transparent about their attempt to repeal the Affordable Care Act (ACA), which narrowly failed. Eight years later lawmakers in both chambers have doubled down on stripping health care from people, first in the House’s 2025 reconciliation bill and now as the Senate considers its version of the bill. The House bill would cause 16 million people to lose their health insurance in the next decade; the Senate version may cause even more damage.

Both bills seek to remove people from health insurance through eligibility changes, increasing red tape and other bureaucratic hurdles to make it too difficult for people to enroll, and allowing people’s monthly premium costs on the Marketplace to skyrocket. Lawmakers are also looking to shift costs to states while reducing their tools for financing Medicaid. If the provisions dismantling the ACA and Medicaid in the reconciliation bill end up on the President’s desk, millions of people will lose their health insurance, costs will soar for millions more, rural hospitals will suffer, and states will face greater budget challenges.

The Senate bill cuts nearly $1 trillion from Medicaid and Marketplace health care, ultimately leaving at least 16 million uninsured and millions more with higher costs to keep their health insurance. Cuts to health care include:

Expanding Eligibility Requirements

Undermining Medicaid expansion as designed in the ACA by creating new eligibility requirements. So-called “work requirements” bury people in paperwork and red tape, making it too difficult to enroll or keep coverage for eligible people. Unlike the House, the Senate bill makes some parents subject to this new eligibility test, which will lead to more people losing their health insurance.

Work reporting requirements do nothing to improve employment, especially living-wage employment that offers health benefits. The truth is that many jobs don’t offer health insurance, and irregular work hours add an extra burden of reporting work hours to the state. The only way to describe “work requirements” is that it is a  Medicaid cut. It’s estimated that this provision alone will cause between 5 million and  14 million people to lose their health insurance. Of the small portion of Medicaid enrollees who are not working and are “able-bodied,” nearly 80 percent are older women who have been caregivers and live in families with very low incomes.

Shifting Costs to Consumers

The Senate bill continues the House tactic of shifting costs to people: specifically, by increasing cost-sharing (up to $35/service for some Medicaid enrollees) and changing rules around retroactive coverage. The Medicaid expansion population includes those with incomes between 100 and 138 percent of the poverty level ($15,650 – $21,127 per year for a single person and $32,150 – $44,367 per year for a family of four). Expecting people at these income levels to pay more out of pocket for care means that they may choose not to access care. That could make it more difficult for people to manage chronic conditions or receive care when they are ill.

Currently, Medicaid helps people avoid medical debt by providing retroactive coverage for 90 days. For example, if an uninsured person who qualifies for Medicaid is admitted to a hospital, they can apply for coverage, including coverage of medical bills in the previous 90 days. This is a safeguard against personal medical debt and helps providers ensure they are paid for their services. The Senate bill limits retroactive coverage to one or two months, depending on the person’s eligibility category.

Adding Red Tape

“Work requirements” will add a massive amount of red tape to Medicaid, but the Senate bill also keeps other bureaucratic provisions from the House version, including increasing the frequency of redeterminations from 12 months to six months. This change both increases the state’s workload and costs and is burdensome to enrollees. It will cause significant churn – eligible people will lose coverage and then re-enroll within a few months. Seven hundred thousand people could lose coverage because of this inefficient and wasteful provision. And, again, this is a direct reversal of a key piece of the ACA, which set a 12-month timeline for Medicaid redeterminations (importantly, if a person’s income changes during that 12-month period, they are required to report the changes to the state).

Lastly, the House and Senate bills both repeal a new regulatory rule that was designed to make Medicaid enrollment more efficient and streamlined for the elderly and people with disabilities. Repealing this rule not only keeps unnecessary red tape and hurdles in place, but will also directly cause people to lose coverage.

Shifting Costs to States

Like the House bill, the Senate puts immense financial pressure on states to pay for costly red tape, administrative hurdles, and lost federal dollars. This is one of many examples in the reconciliation bill where Congress claims to “save” money through cutting “waste” but actually makes states bear the cost instead. Significant resources will be needed for states to build IT systems to handle the new work requirements, and more workers will be needed to process those cases and comply with the new six-month redetermination timeline, which doubles the redetermination administrative work for the Medicaid expansion population. The states will have to pay part of these costs.

The changes to Medicaid financing through provider taxes and state-directed payments will cause states to forgo tens of billions of dollars that are currently used to fund their Medicaid programs—either directly or to shore up hospitals and other providers that, without those dollars, might close. It’s unlikely states will be able to entirely backfill those lost dollars; even if they can, that will come at the expense of other state obligations. Again, this is a cost-shift, not a cost-savings.

Restricting State Funds and Programs

The Senate bill also doubles down on the House plan to penalize states based on how states spend state dollars. Some states choose to spend state dollars to provide health insurance to certain undocumented immigrants. The House and Senate bills both call for penalizing these states by forcing them to double the state share for the Medicaid expansion population. That means that the state would have to pay 20 percent instead of 10 percent due to a decrease in federal funding for the Medicaid expansion population. This is only one of many attacks on immigrant coverage.

This provision is yet another repeal of a core facet of the ACA: a 90 percent federal match for the Medicaid expansion population. States will be forced to choose between keeping their 90 percent match or eliminating a state-funded program.

Repealing Tax Credits

Another pillar of the ACA is the Marketplace and providing tax credits to help people afford insurance. During the pandemic, the tax credits were enhanced, making plans more affordable for millions of people. The Senate bill takes the same position as the House – it does nothing to continue affordable coverage for millions of people. The refusal to extend the enhanced tax credits will cause more than 4 million people to lose coverage due to affordability reasons. Plus, the bills go much further to restrict insurance on the Marketplace by shortening the open enrollment period, changing some of the eligibility rules for special enrollment periods, and requiring more paperwork from applicants.

These attacks on Marketplace coverage are an attack on the ACA. Repealing parts that make it affordable and easy to use may not technically be a repeal of the ACA itself, but millions of people will still lose health insurance.

Drastically Changing Health Care

Some of these changes are clear attacks on people’s health insurance, while others are more in the weeds but also incredibly damaging. Collectively, they drastically alter the landscape of Medicaid , which provides health insurance for 20 percent of the country. While neither the House nor the Senate reconciliation bill explicitly repeals the ACA, all of these cuts and requirements are killing the ACA by a thousand cuts—and harming hospitals, providers, and Americans with low incomes the most.