Tracking the Medicaid Provisions in the 2025 Reconciliation Bill, Kaiser Family Foundation (KFF), Updated: May 19, 2025
Requires states to impose cost sharing of up to $35 per service on expansion adults with incomes 100-138% FPL; maintains existing exemptions of certain services from cost sharing and limits cost sharing for prescription drugs to nominal amounts. Maintains the 5% of family income cap on out-of-pocket costs. Effective Date: October 1, 2028
Reduces the expansion match rate from 90% to 80% for states that use their own funds to provide or support health coverage … for individuals who are not lawfully residing in the US. Effective Date: October 1, 2027
Requires states to condition Medicaid eligibility for individuals ages 19-64 applying for coverage or enrolled through the ACA expansion group on working or participating in qualifying activities for at least 80 hours per month. Effective Date: January 1, 2029
Limits retroactive coverage to one month prior to application for coverage. Effective Date: October 1, 2026
Delays $8 billion annual reductions in subsidies for hospitals with high uninsured and Medicaid rates to September 30, 2028.
Blocks implementation of long term care nurse staffing requirements.
Blocks Medicaid participation for large not-for-profits providing primarily reproductive health care, i.e., Planned Parenthood.
House Republicans’ Medicaid Cuts and Associated Lives Lost, Center for American Progress, May 15, 2025
House Republicans’ radical new budget plan proposes requiring states to implement Medicaid work reporting requirements for adults enrolled through the Affordable Care Act’s (ACA) Medicaid expansion. Under this proposal, nonpregnant, nondisabled, noncaregiver adults ages 19 to 64 would be required to document at least 80 hours per month of work or qualifying activities (such as volunteering) in order to maintain their Medicaid coverage. Otherwise, they would need to seek approval for a qualifying exemption.
Evidence from prior state-level implementations show that bureaucratic paperwork requirements do not increase employment but do result in large-scale coverage losses—even among those who are working or should be exempt from the requirements.
The consequences of such coverage losses, however, are not just administrative: For thousands of Americans, they would be deadly. New estimates from the Center for American Progress show that 6.9 million people losing coverage by 2034 as a result of congressional Republicans’ proposed paperwork requirements would lead to more than 21,600 avoidable deaths nationally each year. [Provides table of avoidable deaths for selected Congressional districts.]
Comment:
By Jim Kahn, M.D., M.P.H.
Medicaid cuts in the House budget reconciliation bill just passed out of committee are a marvel of multidimensionality, severity, lethality, and politically adroitness. One by one:
Multifaceted: As inventoried by KFF, the changes are far-reaching in type, including enrollee cost-sharing, lower federal payments for states supporting undocumented immigrants, a work requirement, limited retroactivity, blocking minimum nursing staffing levels finalized under Biden, and proscribing participation by Planned Parenthood.
Severe: These are huge changes, with outsized increases in state costs; impaired affordability of care for enrollees with tenuous finances; millions of eligible individuals excluded from coverage by onerous (and ineffective) work requirements; dangerous nursing levels; and loss of a highly regarded provider organization. These shifts will massively impair access to care, with millions losing coverage and millions more facing new financial barriers. It will buffet state budgets, particularly in blue states that help the undocumented get coverage.
Deadly: As excerpted above, CAP estimates 21,600 added annual deaths, based on a 2017 study of Medicaid-associated reductions in mortality. Other research supports the substantial life-saving effects of Medicaid, including a comprehensive 2021 study using national surveys and datasets, and a just-published article in Lancet. There’s no question: cutting health insurance kills.
Machiavellian: The political chatter around these expected Medicaid cuts was that they would hurt the GOP in the 2026 midterms and 2028 presidential election. We underestimated the GOP political acumen / deviousness. Note that the most obviously hurtful provisions (e.g., cost-sharing and work requirements) go into effect only in late 2028 / early 2029 – thus minimizing pain to voters and electoral harm to the GOP in the interim. Guess who’ll be blamed by the voters for late 2028 and early 2029 Medicaid cuts? The Dems, if they win. Of course the Dems can cancel the cuts, but not in time to avoid significant political damage. And with GOP tax cuts (for the rich) and the Trump-tariffs-induced economic downturn, the federal budget won’t exactly be flush with funds to restore the program.
It’s truly astounding how complex Medicaid rules, funding, and politics have become. Take an apparently good idea – provide health insurance for the poor – and ultimately what you get is a major political distraction, with the immediate losers being the poor, and the long-term losers being the country. If only, if only … we could figure out a way to pay for health care simply, efficiently, generously … whereby we could remove our medical care from the dirty domain of party politics.
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