Shocker (not): Republicans are going after healthcare for up to 40 million Americans again.

As I noted a few weeks back, the Patient Protection & Affordable Care Act now directly provides healthcare coverage for a stunning 40 million Americans:'s very likely that another 50,000 - 100,000 people will be added to the final QHP tally when the dust settles tomorrow (Tuesday, January 31st) evening. Even assuming the same 94% effectuation rate, that will still bring the effectuated QHP total to roughly 15.4 million.

Add to this the 1,217,517 confirmed Basic Health Plan (BHP) enrollees in New York and Minnesota and the subtotal comes to around 16.62 million QHPs + BHPs combined.

Next, we need to add Medicaid Expansion enrollees.

...the MBES reports only run through March 2022, at which point the national ACA expansion total stood at 22,275,433.

We're up to 38.9 million Americans with ACA coverage already, and we're still missing a lot of Medicaid expansion enrollees.

...Assuming these states are representative, it's safe to assume that Medicaid expansion is up at least 4.3% nationally since March 2022, or around an additional 960,000 people. If you go with the higher end estimate (+5.4%), it would be up over 1.2 million nationally.

That puts the grand total at somewhere between 39.9 - 40.1 million people with ACA-enabled healthcare covered nationally.

That's roughly 12% of the entire U.S. population which has healthcare coverage specifically tied to the ACA.

I'm bringing this up today because it looks like House Republicans have finally introduced their demands (via former Trump Office of Management & Budge Director Russell Vought's "Center for Renewing America") for raising the federal debt ceiling, and it ain't pretty.

via Amy Lotven of Inside Health Policy:

Health care activists Protect Our Care on Thursday (Feb. 23) slammed a budget proposal by a former Trump administration official that would scrap the Affordable Care Act’s subsidies and Medicaid expansion after the Washington Post reported that House GOP lawmakers are open to the plan. The plan avoids making major structural changes to Medicare but calls for about a quarter trillion in payment cuts to the program.

Former Trump-eta Office of Management and Budget Director Russell Vought’s think tank, Center for Renewing America, released the 104-page fiscal 2023 budget proposal on Dec. 7.

“As Republicans hold our economy hostage, they are returning to some of their greatest hits: attacking American health care,” Protect Our Care said in a release. “Behind closed doors, they are relying on a far-right Trump appointee to draft their budget. Vought’s plan would effectively repeal the ACA, driving up costs for almost 15 million Americans and eliminating coverage altogether for more than 20 million people.

...In addition to eliminating the ACA subsidies...the proposal would save $1.1 trillion by repealing the Medicaid expansion and extending work requirements to Medicaid...

The exact wording of these two points, taken directly from the budget proposal itself:

Repeal Obamacare Subsidies: ...Rather than retaining Obamacare’s distortionary regime...the Budget repeals these inflationary subsidies that go to people with incomes as high as $111,000, allowing individuals to purchase the coverage they most value.

...Re-Prioritize Medicaid: The Budget repeals the authorizations created by Obamacare that permit states to expand their Medicaid programs to able-bodied, working-age adults. 

...At the same time, the Budget requires that able-bodied adults of working age work, or look for work, to receive benefits. Current law imposes work requirements for participants in programs like Temporary Assistance for Needy Families (TANF) and the Supplemental Nutrition Assistance Program (SNAP), but does not extend those requirements to recipients of Medicaid benefits.

At first I assumed that they just planned on not allowing the ACA's expanded subsidies (via the American Rescue Plan & Inflation Reduction Act) to be extended (which they should be). If no legislative action is taken to extend these, the ACA will revert back to the less-generous subsidy formula starting in 2026, which would be bad enough.

However, this plan makes it clear that they intend on wiping out all ACA subsidies across the board. While the Protect Our Care press release has it right for the most part, "driving up costs" is actually a massive understatement in my view; it would drive them up so much as to make those policies utterly unaffordable for the vast majority of those 15 million people.

Remember, while the House GOP's 2017 "Repeal/Replace" bill (the AHCA) was a huge pile of crap which was estimated to kick up to 24 million Americans off their healthcare coverage, it at least still would have included some financial assistance to help cover the cost of healthcare premiums. That assistance was stingy as hell, but it was something. The AHCA's biggest attack when it came to the private individual market was on the "Patient Protection" part: The "Blue Leg" requirements like guaranteed issue, community rating, essential health benefits and so forth.

The new proposal by Mr. Vought, however, appears to eliminate nearly all of the ACA's "Green Leg"...while leaving the Blue Leg intact (at least according to this budget proposal, anyway). This would mean everyone would have to pay full price for the comprehensive ACA policies...and seeing how around 90% of ACA enrollees receive financial assistance to help pay for them, that means most of those folks would be screwed. Some earning more than 200% FPL or so might be able to swing downgrading to the dirt-cheapest Bronze plan, but for the most part they'd be SOL.

It's also important to note that this isn't even the full extent of the House GOP plan for gutting healthcare coverage. The plan also calls for, among other things:

  • Eliminating the FMAP Floor: Currently, the federal government covers at least 50% of the cost of Medicaid, with their share increasing from there depending on the average per capita income of the state relative to the national average. The House GOP plan would literally pull the floor out from under that 50% minimum. This would force states to come up with a larger portion of the cost of Medicaid...which in most cases would likely mean reducing the services covered by the program, reducing the number of residents who qualify or both.
  • Continue DSH Reductions: Federal law requires that state Medicaid programs make Disproportionate Share Hospital (DSH) payments to qualifying hospitals that serve a large number of Medicaid and uninsured individuals. These hospitals are essentially acting as "loss leaders" by providing healthcare coverage for less than it costs them to do so. The House GOP plan punishes hospitals for treating undocumented immigrants by starving them of funds for doing so.

Obviously this proposal isn't gonna happen with a Democratic Senate and President Biden in the White House...but it's a clear indicator of what the GOP is gunning for now that they've supposedly "agreed" to take Medicare and Social Security "off the table." And the 1.2 million BHP enrollees would also see every dime of their financial assistance disappear, leaving them high and dry as well.

So yeah, that's around 16.3 million people who'd lose coverage, plus the 23.3 million or so covered by Medicaid via ACA expansion, or around 39.6 million total. Perhaps 35 million if you assume 25% of those with exchange plans was able to stick it out, I suppose...except that there'd also be a ripple effect as insurance carriers immediately bailed out of the ACA exchanges as they saw the subsidies to their no-longer-existing enrollees dry up, which in turn would cause premiums to skyrocket and even more enrollees to drop out, and so on.