17 Million Americans at Risk of Losing Health Coverage by 2034

The Impact of the New Tax and Spending Package on Health Care Access

The recent tax and spending package signed into law by President Donald Trump has significant implications for health care access in the United States. This legislation is expected to reduce government spending on health care by over $1 trillion over the next decade. However, this reduction comes at a cost, with millions of Americans potentially losing their health insurance coverage.

Millions Could Lose Health Insurance Coverage

According to the nonpartisan Congressional Budget Office (CBO), nearly 12 million Americans could lose their health insurance coverage by 2034 due to this legislation. However, the number might be even higher, reaching over 17 million. This includes at least 5 million Americans who currently have Affordable Care Act (ACA) marketplace health insurance and will lose their coverage once subsidies expire at the end of 2025. Very few Republicans have expressed support for renewing these subsidies.

In addition, regulations introduced by the Trump administration earlier in the year are expected to further increase the number of people losing their ACA marketplace coverage. As a public health professor, I see these changes as the first step in reversing the expansion of health care access that began with the ACA's passage in 2010.

Medicaid Coverage at Risk

The biggest impact will be on Americans enrolled in Medicaid, which currently covers more than 78 million people. An estimated 5 million people will eventually lose Medicaid coverage due to new work requirements that will go into effect nationally by 2027. These requirements target individuals eligible through the ACA’s expansion and typically have slightly higher incomes than other Medicaid enrollees.

Medicaid applicants between the ages of 19 and 64 will need to certify they are working at least 80 hours a month or engaging in comparable activities like community service. When similar rules were implemented in other safety net programs, most people lost their benefits due to administrative hassles rather than not meeting the work requirements.

Other increases in paperwork required to enroll in and remain enrolled in Medicaid could render more than 2 million additional people uninsured, according to CBO estimates. Additionally, an extra 1.4 million people may lose coverage if they don’t meet new citizenship or immigration requirements. In total, these changes could lead to over 8 million people becoming uninsured by 2034.

Increased Costs and Reduced Access

Many of those who aren't kicked out of Medicaid will face new copayments of up to $35 for appointments and procedures, making them less likely to seek care even if they still have health insurance. The new policies also make it harder for states to fund Medicaid, which is run by both the federal government and states. By limiting the taxes states charge medical providers, which are used to fund their share of Medicaid, some states may try to reduce enrollment or cut benefits like home-based health care.

Losing Medicaid coverage could leave millions of low-income Americans without insurance, with no affordable alternatives for health care. Historically, those most likely to lose benefits are low-income people of color or immigrants who do not speak English well.

Marketplace Plans Face Challenges

The new law will also make it harder for over 24 million Americans who get health insurance through ACA marketplace plans to remain insured. It will be much harder for Americans to purchase insurance and qualify for subsidies for 2026. Regulations from the Trump administration are expected to lead to almost 1 million people losing their coverage through the ACA marketplace, including reducing spending on outreach and enrollment.

Increased subsidies in place since 2021 are set to expire at the end of the year. Given Republican opposition, it seems unlikely that these subsidies will be extended. Not extending them alone could mean premiums will increase by more than 75% in 2026, leading to an additional 4.2 million Americans losing coverage, according to the CBO.

Broader Implications

When people lose their health insurance, they often end up in worse health, and their medical debts can mount. Early diagnosis is crucial for effective treatment, so those who become uninsured may die sooner than if they had coverage. Struggling to pay high medical bills takes a toll on individuals, families, and communities, as well as on medical providers who don’t get reimbursed for their care.

Public health scholars believe many hospitals and health care providers will have to make tough choices, such as closing, offering fewer services, or firing health care workers. Emergency room wait times will increase for everyone, not just those who lose coverage due to the new legislation.

Rural Hospitals in Crisis

Rural hospitals, already facing a funding crisis, will experience some of the most acute financial pressure. By one estimate, more than 300 hospitals are at risk of closing. Children’s hospitals and hospitals located in low-income urban areas, which disproportionately rely on Medicaid, will also struggle to keep their doors open.

Republicans tried to protect rural hospitals by designating $50 billion in the legislative package for them over 10 years. However, this funding falls far short of the $155 billion in losses KFF expects those health care providers to incur due to Medicaid cuts. Moreover, the funding comes with restrictions that could limit its effectiveness.

What Comes Next

Some Republicans, including Sens. Mike Crapo and Ron Johnson, have indicated that more health care policy changes could come in another large legislative package. These could include harsher provisions left out of the final version of the legislation Congress approved. For example, Republicans may try to roll back the ACA’s Medicaid expansion.

Moving forward, spending on Medicare could also decline. Without further action, the CBO says the law could trigger an estimated $500 billion in mandatory Medicare cuts from 2026 to 2034 due to the trillions of dollars in new federal debt created by the law. Despite Trump’s repeated promises not to cut Medicare or Medicaid, it’s possible the Trump administration will issue executive orders that further reduce federal spending on health care and roll back the coverage gains made by the ACA.