CBO: House Bill Could Increase Uninsured by 16M by 2034

House Republicans have passed the One Big Beautiful Bill Act, a reconciliation package proposing significant changes to Medicaid and ACA Marketplaces. The Congressional Budget Office (CBO) estimates these changes would increase the uninsured population by approximately 10.9 million people. When combined with the expiration of enhanced premium tax credits for ACA Marketplace enrollees, expected later this year, the total number of uninsured could rise by 16 million by 2034 compared to current law scenarios. This legislative package impacts state-level insurance coverage, with 16 states and the District of Columbia potentially seeing uninsured rate increases of 3 percentage points or more solely due to the bill's Medicaid and ACA changes.

CBO's analysis highlights major uncertainty in state responses to Medicaid policy changes, notably Medicaid work requirements which contribute to federal savings but could lead to varying levels of insurance loss depending on state-level implementation. States such as California, Florida, and New York are projected to experience the largest increases in the uninsured population, with 1.7 million, 990,000, and 920,000 respectively. The combined effects of the bill and the expiration of premium tax credits exacerbate coverage loss, particularly in populous states including Florida, Georgia, Louisiana, and Texas.

Medicaid alterations under this bill could result in approximately 10.3 million people losing Medicaid coverage, with an additional 1.4 million losing state-funded health insurance programs for immigrants. These losses directly influence the projected increase in uninsured individuals by state. The CBO allocation accounts for federal funding impacts and states' Medicaid expansion statuses.

Changes to the ACA Marketplaces embedded within the reconciliation bill also contribute to coverage reductions, analyzed in detail based on Energy and Commerce and Ways and Means committee provisions. The impact of the Trump administration's proposed program integrity rule, partially integrated into baseline estimates, further compounds potential coverage losses. Population projections forecasting growth to 2034 facilitate interpretation of percentage point increases in uninsured rates by state.

This analysis underscores the potential ramifications of federal Medicaid and ACA Marketplace policy changes on insurance coverage rates nationwide. It presents a detailed model of state-by-state impacts, offering insights valuable for stakeholders in healthcare policy, payer/provider networks, and regulatory compliance. The evolving Medicaid work requirements and premium tax credit expirations remain critical factors affecting the U.S. health insurance landscape over the coming decade.