Over at the JAMA Network, KFF Executive VP for health policy Larry Levitt has a piece which lays out the most likely actions (or in one case, lack of action) that the incoming Trump Administration & Republican-controlled Congress will take now that they have a second shot at repealing the Affordable Care Act:
With many tax cuts from the 2017 Tax Cuts and Jobs Act expiring at the end of 2025, a high-profile Congressional debate over extending those tax reductions and enacting new ones is likely. There will be pressure from some in Congress for spending cuts to help pay for those tax cuts. Trump has said that Social Security and Medicare cuts are off the table, and defense reductions are unlikely as well. That means almost half of federal spending would be protected from cuts, leaving Medicaid, which is the next largest source of federal spending, and the ACA as prime targets for spending cuts. The math is inescapable.
IMPORTANT: See caveats below regarding the impact of Medicaid Unwinding & other enrollment changes over time on these estimates.
12/12/24: Note: ACA Medicaid Expansion data has been updated by 3 months for most states, from March 2024 to June 2024.
(sigh) Annnnd here we go again. With another GOP trifecta and Trump's Project 2025 promising draconian cuts to federal spending, there's a very good chance that the Affordable Care Act is, once again, on the chopping block.
I have no idea what's going to happen to either it, Medicaid, Medicare, the Children's Health Insurance Program (CHIP), the VA or the Indian Health Service, but whatever it is probably isn't gonna be pretty.
With that in mind, I figured it would be helpful to take stock of just how many Americans are actually receiving healthcare coverage through the ACA...and while I've crunched this number several times before (spoiler: the grand total is a little shy of 45 million people nationally), I'm taking it several steps further this time and breaking it out not only by state, but by Congressional District (CD).
I last checked in on the "Georgia Pathways" program (the Peach State's partial-Medicaid expansion program which offiically extends up to 100% of the Federal Poverty Level but which also includes a draconian work reporting requirement) back in January.
At the time, only around 2,500 Georgians had actually enrolled in Georgia Pathways, for a number of rather obvious reasons:
Back in May I noted that North Carolina's ACA Medicaid expansion initiative, which started in December 2023, had officially enrolled more than 450,000 of the estimated 600,000 NC residents eligible for the program.
North Carolina Celebrates More Than 500,000 Enrolled in Medicaid Expansion
PRESS RELEASE — More than half a million North Carolinians have now enrolled in Medicaid expansion since the program began seven months ago. Beneficiaries are now able get the quality health care they need at low cost. Governor Roy Cooper was joined by North Carolina Department of Health and Human Services Secretary Kody Kinsley, Dr. Karen L. Smith MD, FAAFP, a family physician in Raeford and Verlina Lomick,CHW-IV, Director of Community Outreach & Advocacy for Kintegra Health and health care advocates to celebrate reaching this major milestone, which had originally been projected to take as long as two years.
Across these 19 states alone, ACA Medicaid expansion enrollment is up 788,245 people since last March, or 6.7% overall. If you remove Missouri and Oklahoma, it's still up 4.28% since then, and again, this is still as much as 8 months out of date depending on the state. Assuming Illinois is wrong, removing it as well puts expansion enrollment up 5.4% since last March.
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.
Last month I noted that North Carolina's ACA Medicaid expansion initiative, which started in December 2023, had officially enrolled more than 400,000 of the estimated 600,000 NC residents eligible for the program.
The data comes from the Centers for Medicare & Medicaid Services quarterly Medicaid Budget & Expenditure System reports. Unfortunately, the MBES reports only ran through June of last year, so it was missing the last half of the year...which is pretty important since that's when the drop in Medicaid coverage due to the ongoing Unwinding process really started to kick in.
Fortunately, CMS recently updated the MBES data to include the third quarter of 2023, bringing Medicaid enrollment *up through September. It's still 8 months out of date but it's better than nothing.
Note: Medicaid expansion enrollment actually peaked in May 2023 at just shy of 24.8 million, but the graph below only includes 6-month increments (January/June).
As of September 2023, MBES put Medicaid expansion enrollment at 23,225,220 nationally.
No further analysis or comment here; I just think this is a pretty cool graphic...and keep in mind that most of the people represented here would have been utterly screwed from early 2020 - early 2023 without the Affordable Care Act being in place when the pandemic hit.
Click the image for a higher-resolution version; the states are listed on the right-hand side, though they might be difficult to make out (also note that Guam, Puerto Rico and the U.S. Virgin Islands also have a number of ACA expansion enrollees shown):
I strongly suspect that at least one of the remaining holdout states will join the expansion crowd this year, most likely Georgia, Mississippi or Alabama...but it likely will be some state-specific variant as described above. Stay tuned...
...As I noted, however, in all three [states] it's pretty likely they'll go with at least a partially privatized version as Arkansas has instead of a "clean" expansion of Medicaid proper.
February 28th:
BREAKING: The Mississippi House just passed Medicaid expansion by a 96-20 vote.
That's more than enough to overcome a veto from Gov. Tate Reeves.
It now heads to the Senate.
I strongly suspect that at least one of the remaining holdout states will join the expansion crowd this year, most likely Georgia, Mississippi or Alabama...but it likely will be some state-specific variant as described above. Stay tuned...
...As I noted, however, in all three [states] it's pretty likely they'll go with at least a partially privatized version as Arkansas has instead of a "clean" expansion of Medicaid proper.
February 28th:
BREAKING: The Mississippi House just passed Medicaid expansion by a 96-20 vote.
That's more than enough to overcome a veto from Gov. Tate Reeves.
It now heads to the Senate.
Today, Governor Cooper announced that more than 400,000 North Carolinians now have access to health care through the state’s Medicaid expansion following record enrollment numbers and a coordinated campaign to enroll North Carolinians across the state.
“So many younger, working people desperately need affordable health insurance and Medicaid Expansion fills the bill for thousands of them and with people all the way through age 64,” said Governor Roy Cooper. “This milestone and the speed at which we’ve reached it shows just how lifechanging Medicaid expansion is for our state and we will continue to get more eligible North Carolinians enrolled.”
