A nurse gives a patient a checkup at an Oakland, California, clinic in 2017. (Carlos Avila Gonzalez/The San Francisco Chronicle via Getty Images)

Medicaid, the joint federal-state health insurance program that covers about one-in-five Americans, may be in for some of the biggest changes in its 60-year history.

The tax, spending and policy bill making its way through Congress seeks to cut hundreds of billions of dollars from Medicaid over the next decade to help offset the measure’s even larger tax cuts. The Congressional Budget Office estimates that the Medicaid cuts, along with changes to other federal insurance programs, would lead to millions of people losing health coverage should the bill become law.

Given the changes that may be in store for the program and its overall complexity, here are answers to some common questions about Medicaid.

What is Medicaid?

Medicaid provides health insurance to various categories of low-income people. It’s funded jointly – though not equally – by the federal government and the states. However, the way the program is structured and run means that in many ways there’s no single Medicaid program. Rather, there are 56: one for each state, the District of Columbia and the five permanently inhabited U.S. territories.

Medicaid was created in 1965 at the same time as Medicare, the federal health insurance program primarily for people ages 65 and older. Both programs are overseen by the Centers for Medicare & Medicaid Services (CMS), an agency within the U.S. Department of Health and Human Services.

The Children’s Health Insurance Program (CHIP), created in 1997, is designed to cover children from families whose incomes are modest but too high to qualify for Medicaid. While CHIP is formally separate from Medicaid, the two programs are closely coordinated in practice. In fact, some states administer CHIP as an extension of their Medicaid programs, while others either operate CHIP separately or combine the two approaches. This analysis will present data for Medicaid and CHIP separately when possible.

Medicaid is broadly popular. More than eight-in-ten U.S. adults (83%) have a favorable opinion of the program, according to a recent survey by KFF, a nonpartisan research organization focused on health policy. That view is shared by 93% of Democrats, 74% of Republicans and 83% of independents.

Is Medicaid eligibility determined by the federal government or the states?

Both. The federal government sets general rules about who always qualifies for Medicaid and which health care services must be covered. Beyond that, states have considerable flexibility to determine the scope of their programs by extending eligibility to additional groups of people (or not) and covering various optional health care services (or not).

For example, under the federal Affordable Care Act of 2010, states can expand eligibility to adults with household incomes up to 138% of the federal poverty level – which in 2025 would be $44,367 for a family of four – with the federal government picking up 90% of the additional cost. Forty states and D.C. have expanded their Medicaid programs in this way, while the other 10 states have not.

Who’s eligible for Medicaid?

Originally, Medicaid was aimed at certain categories of low-income people: families with children, pregnant women, and the elderly, blind or disabled. People in those groups who received some form of public assistance generally also qualified for Medicaid coverage.

Those eligibility groups have broadened over time. States are required to cover some groups – for instance, children in foster care and former foster care youth up to age 26. Coverage is optional for others – for example, pregnant women and infants in households with incomes between 133% and 185% of the federal poverty level. Since each state sets its own eligibility criteria (within broad federal minimums), there’s no simple way to summarize them.

In fiscal year 2022, 36% of all Medicaid enrollees were children, according to the Medicaid and CHIP Payment and Access Commission. Another 26% were adults who had become eligible under the 2010 Affordable Care Act; 18% were adults who’d already been eligible; and 20% were elderly, blind or disabled.

How many people have Medicaid coverage?

As of January 2025, 71.4 million people were enrolled in Medicaid, according to preliminary CMS data. An additional 7.3 million were enrolled in CHIP. Together, the two programs covered nearly 41.4 million adults and 37.4 million children, or 23% of the U.S. population.

Children are covered by Medicaid at a higher rate than adults. We estimate that 41% of all U.S. children were enrolled in Medicaid and 10% were enrolled in CHIP as of January. The two programs combined provided health coverage to more than half of the country’s 73.1 million children. By comparison, Medicaid enrolled 15% of the U.S. adult population as of January.

How has Medicaid enrollment changed over time?

While the long-term trend has been upward, Medicaid enrollment has remained relatively steady for the past several years at around 20% of the U.S. population.

Medicaid enrollment counts are affected by factors including population growth and general economic conditions, since more people become eligible in downturns as they lose jobs and income. But policy changes play a significant role as well: Congress and individual states can expand or restrict eligibility rules and, separately, make it easier or harder for people to enroll and maintain their eligibility status.

During the COVID-19 pandemic, for example, Congress gave states extra money for their Medicaid programs on the condition that they maintain coverage for nearly everyone who was already enrolled in the program (rather than periodically rechecking their eligibility, as is normally required). This “continuous coverage” rule led to a steep rise in enrollment, from 64.8 million in March 2020 to a peak of 87.4 million in April 2023 – an increase of 34.8%.

The extra funds began to phase out in April 2023 and ended completely, along with the continuous coverage requirement, that December. Medicaid enrollment has fallen steadily since then, to 21% of the U.S. population as of January 2025.

How do Medicaid enrollment rates vary around the country?

In January 2025, by our calculations, Medicaid enrollment ranged from a high of 34.2% of the population in D.C. to a low of 8.6% in Utah. Enrollment in CHIP ranged from 4.4% in Oregon to 0.1% in Minnesota. Again, state enrollment rates in these programs depend on factors including local economic conditions and each state’s eligibility rules.

Detailed table: Medicaid enrollment by state in January 2025

What are the demographics of Medicaid enrollees?

Here’s some of what we know, based on 2023 data from the Current Population Survey’s Annual Social and Economic Supplement, or ASEC. (Note that ASEC defines Medicaid to include CHIP and a handful of other state-administered programs for low-income people.)

Women account for just over half of Medicaid enrollees (52.2%), slightly higher than their share of the overall U.S. population (50.7%).

Non-Hispanic White enrollees account for 39.6% of all Medicaid recipients (versus 58.0% of the U.S. population as a whole). Hispanic people, who can be of any race, comprise 30.8% of enrollees (versus 19.7% of the population), and Black people make up 20.8% of enrollees (versus 13.5% of the population). The share of Asian American enrollees (6.0%) was about the same as their share of the overall population (6.6%).

Medicaid enrollees ages 19 to 64 are more likely than Americans in that age group overall to have never been married (47.9% vs. 36.3%) or to be divorced or separated (14.8% vs. 11.1%). They’re much less likely than Americans overall to be currently married (34.9% vs. 51.0%).

Nearly half of enrollees (48.6%) have household incomes of less than $50,000, compared with 23.8% of the general population.

More than half (57.2%) of enrollees ages 26 to 64 have a high school diploma or less, compared with 34.9% of the population in that age group.

17.0% of enrollees rate their health status as “fair” or “poor,” compared with 11.2% of all people surveyed.

84.2% of Medicaid enrollees were born in the United States, 6.6% are naturalized citizens and 9.2% are foreign-born noncitizens. Those shares are all similar to the U.S. population as a whole. Only some noncitizens are eligible for Medicaid; unauthorized immigrants are not eligible for the program.

Are Medicaid enrollees required to work?

In most cases, no. But under the budget legislation pending in Congress, people who qualify for Medicaid under the 2010 Affordable Care Act expansion would have to work, do community service or go to school to retain their eligibility. (Georgia operates a pilot work requirement under a waiver approved during the first Trump administration.)

In a recent Pew Research Center survey, 49% of U.S. adults said they would favor work requirements for most adults who get health insurance through Medicaid, while 32% would oppose such requirements and 18% weren’t sure.

Most working-age adult enrollees in Medicaid already work, according to a May 2025 analysis by KFF.

Just over 31.2 million people ages 19 to 64 were enrolled in Medicaid in 2023, KFF found. More than 2.4 million of them were also covered by Medicare, and 2.7 million received disability benefits from Social Security or Supplemental Security Income benefits. Excluding those two groups of people, who presumptively have disabilities that would exempt them from the work requirements, leaves 26.1 million enrollees. Among that group, 11.5 million worked full time (44.1%) and 5.1 million worked part time (19.5%).

Of the 9.5 million people who didn’t work, 3.2 million cited caregiving responsibilities as a reason, while 1.7 million said they were in school and 2.6 million cited illness or disability.

How much does Medicaid cost?

In fiscal 2023, the most recent year for which detailed financial information is available, Medicaid’s net cost was $894.2 billion. The federal government paid just over two-thirds of that figure ($614.0 billion, or 68.7%), while states, D.C. and territories paid the rest ($280.2 billion, or 31.3%).

Under Medicaid, states pay health care providers up front. The federal government then reimburses states for part of those costs. Those federal payments are a lot larger in some states than others. In fiscal 2023, for example, the federal government paid for 82.1% of New Mexico’s program, 71.0% of Tennessee’s and 59.7% of Wyoming’s. The federal shares of the territories’ programs were all 85% or higher.

The federal matching rates vary because they’re based largely on each state’s per-capita income and are recalculated each year based on new data. In addition, certain services and subgroups of enrollees are reimbursed at their own specific rates.

Historically, the federal government’s overall share of Medicaid costs has hovered between 56% and 59%, though Congress has often raised matching rates temporarily during economic downturns.

The federal share rose above 60% and stayed there after the Affordable Care Act expanded Medicaid eligibility. During the COVID-19 pandemic, when Congress authorized extra payments to states for retaining people on the rolls, the federal share reached as high as 71% (in fiscal 2022).

How much of federal and state budgets go to Medicaid?

In fiscal 2024, Medicaid represented about 8% of all federal spending, according to archived data from the Office of Management and Budget. This was down from a peak of 10% the year before. Medicaid’s share of federal spending grew steadily from the program’s inception until the 2004 fiscal year, and since then it has bounced around more erratically.

State spending on Medicaid varies considerably. Because much of what states spend on Medicaid is ultimately reimbursed by the federal government, a better way to analyze the program’s budget impact is to look only at “locally raised dollars” spent on Medicaid as a share of all locally raised money spent. (We’re using “locally raised dollars” to mean money raised by state and local taxes, fees and assessments, or borrowed by states, whether held in their general funds or other specialized funds.)

Considered that way, Missouri spent the most in fiscal 2023. It spent 25.5% of its locally raised dollars on Medicaid, according to data from the National Association of State Budget Officers. Hawaii spent the least of any state at 5.7% of its locally raised dollars.

Where does all that money go?

In fiscal 2023, a total of $884.4 billion was spent on medical services through Medicaid, according to our analysis of CMS financial data. (That figure includes rebates and offsets of various kinds but excludes $24.5 billion collected from patients and third parties. Net spending on services was $859.9 billion.)

More than half of that money ($460.6 billion, or 52.1%) went to managed-care organizations, or MCOs. Most Medicaid beneficiaries – 85% in 2022 – are enrolled in some type of managed-care plan. Under such plans, states contract with MCOs and pay a fixed monthly fee per enrollee. The MCO then either provides health care services to beneficiaries itself or pays providers to do so.

Almost $112.8 billion (or 12.8%) was spent on home- and community-based long-term care services, while another $60.4 billion (or 6.8%) went for institutional long-term care. All told, 19.6% of all Medicaid spending went to long-term care.

Another $87.9 billion, or nearly 10%, went to hospitals, and $18.8 billion (2.1%) went toward prescription drugs. About $27.6 billion (3.1%) went to pay Medicare premiums and copays for low-income elderly people who receive both Medicaid and Medicare benefits.

In addition, $34.4 billion went to federal and state administrative expenses, amounting to 3.8% of net spending.

How big a role does Medicaid play in U.S. health care overall?

In 2023, Medicaid accounted for 17.9 cents of every dollar spent on health care in the United States, according to health expenditure data from CMS. Excluding medical research and spending on buildings and medical equipment – which Medicaid doesn’t pay for at all – the program paid 18.8 cents of every dollar spent on health care services. Since about 1990, Medicaid’s share of overall health spending has mostly grown, albeit in fits and starts.

Medicaid is a much more significant player in particular areas. For example, in 2023, more than a third of home health care spending and nearly a third of spending on nursing homes came via Medicaid, according to CMS. That same year, Medicaid paid for 41% of births in the country, according to data from the Centers for Disease Control and Prevention.

This brief was updated on July 11, 2025 to include the latest KFF polling data.

For many years, KFF polling has found that the high cost of health care is a burden on U.S. families, and that health care costs factor into decisions about insurance coverage and care seeking. These costs and the prospect of unexpected medical bills also rank as the top financial worries for adults and their families. This data note summarizes recent KFF polling on the public’s experiences with health care costs. Main takeaways include:

Just under half of U.S. adults say it is difficult to afford health care costs, and one in four say they or a family member in their household had problems paying for health care in the past 12 months . Black and Hispanic adults, those with lower incomes, and the uninsured are particularly likely to report problems affording health care in the past year.

. Black and Hispanic adults, those with lower incomes, and the uninsured are particularly likely to report problems affording health care in the past year. The cost of health care can lead some to put off needed care . About one-third (36%) of adults say that in the past 12 months they have skipped or postponed getting health care they needed because of the cost. Notably three in four (75%) uninsured adults under age 65 say they went without needed care because of the cost.

. About one-third (36%) of adults say that in the past 12 months they have skipped or postponed getting health care they needed because of the cost. Notably three in four (75%) uninsured adults under age 65 say they went without needed care because of the cost. The cost of prescription drugs prevents some people from filling prescriptions . About one in five adults (21%) say they have not filled a prescription because of the cost while a similar share (23%) say they have instead opted for over-the-counter alternatives. About one in seven adults say they have cut pills in half or skipped doses of medicine in the last year because of the cost. A third of all adults say they have taken at least one of these cost saving measures in the past year, including larger shares of women and those with lower incomes.

. About one in five adults (21%) say they have not filled a prescription because of the cost while a similar share (23%) say they have instead opted for over-the-counter alternatives. About one in seven adults say they have cut pills in half or skipped doses of medicine in the last year because of the cost. A third of all adults say they have taken at least one of these cost saving measures in the past year, including larger shares of women and those with lower incomes. Health care debt is a burden for a large share of Americans . In 2022, about four in ten adults (41%) reported having debt due to medical or dental bills including debts owed to credit cards, collections agencies, family and friends, banks, and other lenders to pay for their health care costs, with disproportionate shares of Black and Hispanic adults, women, parents, those with low incomes, and uninsured adults saying they have health care debt.

. In 2022, about four in ten adults (41%) reported having debt due to medical or dental bills including debts owed to credit cards, collections agencies, family and friends, banks, and other lenders to pay for their health care costs, with disproportionate shares of Black and Hispanic adults, women, parents, those with low incomes, and uninsured adults saying they have health care debt. Those who are covered by health insurance are not immune to the burden of health care costs . Almost four in ten insured adults under the age of 65 (38%) worry about affording their monthly health insurance premium and large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as “fair” or “poor” when it comes to their monthly premium and to out-of-pocket costs to see a doctor.

. Almost four in ten insured adults under the age of 65 (38%) worry about affording their monthly health insurance premium and large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as “fair” or “poor” when it comes to their monthly premium and to out-of-pocket costs to see a doctor. Notable shares of adults say they are worried about affording medical costs such as the cost of health care services (including out-of-pocket costs not covered by insurance, such as co-pays and deductibles) or unexpected bills. About six in ten adults say they are either “very” or “somewhat worried” about being able to afford the cost of health care services (62%) or unexpected medical bills (61%) for themselves and their families.

Difficulty Affording Medical Costs

Many U.S. adults have trouble affording health care costs. While lower income and uninsured adults are the most likely to report this, those with health insurance and those with higher incomes are not immune to the high cost of medical care. Just under half of U.S. adults say that it is very or somewhat difficult for them to afford their health care costs (44%). Uninsured adults under age 65 are much more likely to say affording health care costs is difficult (82%) compared to those with health insurance coverage (42%). Additionally, a slight majority of Hispanic adults (55%) and half of Black adults (49%) report difficulty affording health care costs compared to about four in ten White adults (39%). Adults in households with annual incomes under $40,000 are more likely than adults in households with higher incomes to say it is difficult to afford their health care costs. (Source: KFF Health Tracking Poll: May 2025)

When asked specifically about problems paying for health care in the past year, about one in four (23%) adults say they or a family member in their household had problems paying for care, including three in ten Hispanic adults (33%) and Black adults (30%). Over half (55%) of uninsured adults under age 65 say they or a family member in their household had problems paying for health care, compared to just one in five (22%) insured adults. (Source: KFF Health Tracking Poll: May 2025)

The cost of care can also lead some adults to skip or delay seeking services, with one-third (36%) of adults saying that they have skipped or postponed getting needed health care in the past 12 months because of the cost. Women are more likely than men to say they have skipped or postponed getting health care they needed because of the cost (38% vs. 32%). Adults ages 65 and older, most of whom are eligible for health care coverage through Medicare, are much less likely than younger age groups to say they have not gotten health care they needed because of cost.

Three-quarters of uninsured adults say they have skipped or postponed getting the health care they needed due to cost. Having health insurance, however, does not offer ironclad protection as about four in ten adults with insurance (37%) still report not getting health care they needed due to cost. (Source: KFF Health Tracking Poll: May 2025)

Skipping care due to costs can have notable health impacts. Nearly two in ten adults (18%) report that their health got worse because they skipped or delayed getting care. Among adults under age 65, those who are uninsured are twice as likely as those with health coverage to say that their health worsened due to skipped or postponed care (42% vs. 20%). About four times as many adults under age 65 (23%) say their health got worse after skipping or postponing care as adults ages 65 and older (6%), most of whom have Medicare coverage. (Source: KFF Health Tracking Poll: May 2025)

A 2022 KFF report found that people who already have debt due to medical or dental care are disproportionately likely to put off or skip medical care. Half (51%) of adults currently experiencing debt due to medical or dental bills say in the past year, cost has been a probititor to getting the medical test or treatment that was recommended by a doctor. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022)

Prescription Drug Costs

The high cost of prescription drugs also leads some people to cut back on their medications in various ways. About one in four adults (23%) say in the past 12 months they have taken an over-the-counter drug instead of getting a prescription filled because of cost concerns and about one in five (21%) say they have not filled a prescription due to the cost. Additionally, about one in seven adults (15%) say that in the past 12 months they have cut pills in half or skipped doses of medicine due to cost.

One-third of the public (33%) say they have taken any of these cost saving measures in the past 12 months. Four in ten women (39%) say they have taken any of these prescription medication measures compared to one-quarter (26%) of men. Additionally, just under half of Hispanic adults (46%) say they’ve either taken an over-the-counter drug, skipped doses, or not filled prescriptions because of the cost, compared to three in ten (29%) White adults who say the same. Similarly, larger shares those with lower incomes report having taken a cost-saving measure in the last year compared to those with higher incomes (41% of those with a household income of less than $40,000 a year vs. 29% of those with an income of $40,000 or more). (Source: KFF Health Tracking Poll: May 2025)

Notably, adults with chronic conditions, who tend to have higher health care and medication needs, can often face challenges affording prescriptions. In KFF’s 2023 Survey of Consumer Experiences with Health Insurance, insured adult with a chronic condition were twice as likely as those without a chronic condition to say they had delayed or gone without prescription drugs due to the cost (18% vs. 9%).

Health Insurance Cost Ratings

Health insurance provides some financial protection, but premiums and out-of-pocket costs can still present a financial burden for many individuals. Overall, most insured adults rate their health insurance as “excellent” or “good” when it comes to the amount they have to pay out-of-pocket for their prescriptions (61%), the amount they have to pay out-of-pocket to see a doctor (53%), and the amount they pay monthly for insurance (54%). However, at least three in ten rate their insurance as “fair” or “poor” on each of these metrics, and affordability ratings vary depending on the type of coverage people have.

Adults who have private insurance through employer-sponsored insurance or Marketplace coverage are more likely than those with Medicare or Medicaid to rate their insurance negatively when it comes to their monthly premium, the amount they have to pay out of pocket to see a doctor, and their prescription co-pays. About one in four adults with Medicare give negative ratings to the amount they have to pay each month for insurance and to their out-of-pocket prescription costs, while about one in five give their insurance a negative rating when it comes to their out-of-pocket costs to see a doctor.

Medicaid enrollees are less likely than those with other coverage types to give their insurance negative ratings on these affordability measures (Medicaid does not charge monthly premiums in most states, and copays for covered services, where applied, are required to be nominal). (Source: KFF Survey of Consumer Experiences with Health Insurance)

Health Care Debt

In June 2022, KFF released an analysis of the KFF Health Care Debt Survey, a companion report to the investigative journalism project on health care debt conducted by KFF Health News and NPR, Diagnosis Debt. This project found that health care debt is a wide-reaching problem in the United States and that 41% of U.S. adults currently have some type of debt due to medical or dental bills from their own or someone else’s care, including about a quarter of adults (24%) who say they have medical or dental bills that are past due or that they are unable to pay, and one in five (21%) who have bills they are paying off over time directly to a provider. One in six (17%) report debt owed to a bank, collection agency, or other lender from loans taken out to pay for medical or dental bills, while similar shares say they have health care debt from bills they put on a credit card and are paying off over time (17%). One in ten report debt owed to a family member or friend from money they borrowed to pay off medical or dental bills.

While four in ten U.S. adults have some type of health care debt, disproportionate shares of lower income adults, the uninsured, Black and Hispanic adults, women, and parents report current debt due to medical or dental bills.

Vulnerabilities and Worries About Health Care and Long-Term Care Costs

KFF’s May 2025 Health Tracking Poll shows the cost of health care services and unexpected medical bills are at the top of the list of people’s financial worries, with about six in ten saying they are at least somewhat worried about affording the cost of health care services (62%) or unexpected medical bills (61%) for themselves and their families. These are larger than the shares who say they worry about affording housing costs (51%), transportation expenses (50%), utilities (49%), and food (48%) for their families.

Notably, eight in ten uninsured adults under age 65 say they are worried about affording the cost of health care services or unexpected medical bills (82% and 80%, respectively). About four in ten (38%) insured adults under the age of 65 say they are worried about affording their monthly health insurance premium. (Source: KFF Health Tracking Poll: May 2025)

Many U.S. adults may be one unexpected medical bill from falling into debt. About half of U.S. adults say they would not be able to pay an unexpected medical bill that came to $500 out of pocket. This includes one in five (19%) who would not be able to pay it at all, 5% who would borrow the money from a bank, payday lender, friends or family to cover the cost, and one in five (21%) who would incur credit card debt in order to pay the bill. Women, those with lower household incomes, Black and Hispanic adults are more likely than their counterparts to say they would be unable to afford this type of bill. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022)

Among older adults, the costs of long-term care and support services are also a concern. Almost six in ten (57%) adults 65 and older say they are at least “somewhat anxious” about affording the cost of a nursing home or assisted living facility if they needed it, and half say they feel anxious about being able to afford support services such as paid nurses or aides. These concerns also loom large among those between the ages of 50 and 64, with more than seven in ten saying they feel anxious about affording residential care (73%) and care from paid nurses or aides (72%) if they were to need these services. See The Affordability of Long-Term Care and Support Services: Findings from a KFF Survey for a deeper dive into concerns about the affordability of nursing homes and support services.

The Medicaid cuts in President Donald Trump’s domestic policy bill could result in more than 1,000 additional deaths every year, according to a report published Wednesday in JAMA Health Forum.

The cuts could also lead to nearly 100,000 more hospitalizations each year, the report found, and around 1.6 million people may delay seeking care.

The projections are at odds with comments made by Health and Human Services Secretary Robert F. Kennedy Jr., who downplayed the bill’s impact during an interview with Fox Business Network’s Larry Kudlow on Monday.

“We’re not going to cut Medicaid and there’s nobody who is going to die from this,” Kennedy said.

HHS did not immediately respond to request for comment.

Wednesday’s study reaches a similar conclusion to an analysis published in the Annals of Internal Medicine in June, which also found that the cuts could lead to thousands of preventable deaths annually because people delay care and get sicker.

Medicaid is jointly funded by states and the federal government.

Trump’s legislation — dubbed the “big, beautiful bill” — includes nearly $1 trillion in cuts to the program, mainly through work requirements and reduced federal funding. Most of the changes aren’t slated to take effect until 2027 or 2028.

The new report’s projections are based on an earlier estimate from the Congressional Budget Office that found changes to Medicaid could result in 7.6 million people in the U.S. losing their health insurance by 2034.

The coverage losses are expected to lead people to delay seeking care because they can no longer afford it, said the report’s author, Dr. Sanjay Basu, the chief medical officer at Waymark, a company that aims to improve access and care to Medicaid patients. For many, he said, that delay would result in people getting sicker, leading to hospitalizations and death.

“People tend to worry about cost or coverage,” he said, so they avoid care until “they end up hospitalized or found at home, dead, from an uncontrolled condition.”

Basu added that the report’s projections are likely “an underestimate,” noting that it doesn’t take into account changes in the bill to the Affordable Care Act.

The estimates also assume that states will be able to make the required changes to their Medicaid programs — such as setting up systems to track work requirements — within the two- to three-year time period, he said.

A worst-case scenario in the report projects double the number of additional annual deaths — around 2,000 — and estimates that up to 2.5 million people will delay seeking care.

“This stuff is actually quite complicated for a state, and the deadlines are not too long from now,” Basu said. “We’re not sure how many people will be dropped, not because they’re no longer eligible, but because they procedurally can’t get through things.”

Other health impacts

Jennifer Tolbert, deputy director of the program on Medicaid and the uninsured at the health policy research group KFF, said other studies have repeatedly shown that uninsured people are less likely than those with insurance to get preventive care and treatments for major health conditions and chronic diseases.

Almost a third of uninsured adults report delaying or forgoing care due to cost, compared with 6% of insured adults, according to a KFF report.

“The consequences [of delaying care] can be severe,” she said, “particularly when preventable conditions or chronic diseases go undetected.”

In addition to people delaying care, 1.9 million people each year are projected to skip, delay or not take their medication as prescribed, according to the new report.

The cuts are also projected to lead to an additional $7.6 billion in medical debt in the U.S.

By 2034, more than 100 rural hospitals could be at risk of closure, the report found. More than 300,000 jobs could be lost, and the economy could shrink by about $135 billion, the report said. (In the worst-case scenario, the job losses were 408,000 and the economy took a $182 billion hit.)

Dr. Benjamin Sommers, a physician and health economist at Harvard T.H. Chan School of Public Health, said people often don’t find out they’ve lost coverage until they go see their doctor and can face huge bills.

Sommers published a study in the New England Journal of Medicine in 2019 looking at the impact of Arkansas’ Medicaid work requirements. The program ended after only 10 months, before any clear data on hospitalizations or deaths was available.

“There are a lot of different ways people can experience this type of bureaucracy,” he said. “The red tape, starting with just not even understanding what the policy means and how it applies to them.”

Proposed cuts to health insurance programs in the budget bill being pushed through Congress by President Donald Trump could put hundreds of thousands of health care jobs at risk — jeopardizing one of the few notably strong areas of the U.S. job market.

Congressional Republicans are advancing a budget plan that would cause nearly 8 million people on Medicaid to lose their health insurance coverage, according to estimates by the Congressional Budget Office, with an additional 2 million people to lose coverage through the Affordable Care Act if Congress remains on track to let health insurance tax subsidies expire at the end of the year.

Less funding for Medicaid and fewer people with health insurance would mean a drop-off in doctor’s office visits, prescription refills and medical procedures — and, as a result, fewer workers needed to support those types of services. It could lead to the loss of nearly 500,000 health care jobs over the next decade, according to an analysis by George Washington University and the Commonwealth Fund. The expiration of the ACA tax subsidies, which were enacted in 2021, would result in the loss of an additional 140,000 jobs, a separate analysis from George Washington University found.

“Hospitals will close, health centers will close, pharmacies in some parts of the country will close because they will lose revenue,” said Leighton Ku, director for the Center for Health Policy Research at George Washington University, who worked on the analyses. “There are going to be job losses, and we’re talking about middle class jobs being lost.”

That would be a blow to one of the strongest, steadiest areas of the job market in recent years. Health care accounted for nearly half of the jobs added in the U.S. in May, according to the Bureau of Labor Statistics. Last year, around half of the 2.2 million jobs added to the economy were in health care-related sectors, according to an analysis by S&P Global. That has helped offset job cuts and stagnant growth in other sectors of the labor market, like retail and manufacturing.

“Right now, a lot of what is driving these positive headline numbers and bolstering the labor market is the health care sector,” said Allison Shrivastava, an economist with job listing site Indeed.com. “It’s something that has been a constant. The health care sector has been a pretty big mainstay as the rest of the labor market has cooled.”

The health insurance provisions are part of a broader spending bill that has passed the House and is currently making its way through the Senate. The legislation, which Republicans have dubbed the “Big Beautiful Bill Act,” would cut around $800 billion from Medicaid, the health insurance program for the poor and disabled, in order to help offset some of the $4 trillion in tax cut extensions in the bill for individuals and corporations.

A version of the bill currently in the Senate, which plans to start voting on the legislation next week, would go even further in reducing spending on Medicaid, by including a provision to limit states’ use of taxes on hospitals and other health care providers that help states fund their share of the Medicaid program.

The cuts would take a particular toll on health care providers in rural areas, where patients are more likely to be insured through Medicaid than those in metro areas. Researchers at Georgetown University found that 40% of children in small and rural towns receive their health insurance from Medicaid.

Already, one-third of all rural hospitals in the country are at risk of closing because of financial difficulties, according to a report this month from the Center for Healthcare Quality and Payment Reform.

Also at risk are Community Health Centers, which employ more than 300,000 workers and receive a portion of their funding from the federal government. Those centers, which serve at least 32 million mostly lower-income patients a year, get about 40% of their revenue from Medicaid.

“Our health centers operate on razor-thin margins, so any kind of disruption in payments or reimbursements, even for a short time, can have a significant impact,” said Joe Dunn, chief policy officer for the National Association of Community Health Centers. “About 40% of health centers are in rural America, and oftentimes they are the only primary care in that community. We have health centers in towns of a few hundred people, and there may not be any other kind of health care network there.”

Absent any policy changes from Congress, the health care sector had appeared to be on track for continued growth — and largely isolated from wider concerns about tariffs and an economic slowdown. The number of job postings for doctors and surgeons on Indeed.com are about 90% higher than their pre-pandemic levels, listings for home health aides are up 46%, and openings for nurses are up 16%, Shrivastava said.

Health care job postings on ZipRecruiter.com represent 27% of all active job listings and health care postings are beginning to make up a larger share of new job postings, according to data from ZipRecruiter.

A loss of that hiring momentum from funding cuts would leave one less positive driver for the job market.

“Right now, the labor market as a whole is arguably in a stagnant position,” said Shrivastava. “People are not wanting to leave their jobs, they’re nervous about whether or not they’ll be able to find another job, and companies aren’t really looking to hire. Health care has been the exception to that.”

On May 22, the House passed a reconciliation bill, the One Big Beautiful Bill Act, which would partially pay to extend expiring tax cuts by cutting Medicaid. The Congressional Budget Office (CBO) estimates that the bill would reduce federal Medicaid spending by $793 billion over ten years and 10.3 million fewer people would be enrolled in Medicaid in 2034, including 1.3 million people with Medicare, otherwise known as “dual-eligible individuals”. The loss of Medicaid coverage for Medicare beneficiaries stems from delaying implementation of two rules that aimed to streamline the enrollment process and make it easier for people to maintain Medicaid coverage by reducing administrative barriers. Dual-eligible individuals would be disproportionately impacted by these provisions, comprising nearly 60% of the 2.3 million Medicaid enrollees who are estimated to lose coverage as a result of delaying these rules under the House reconciliation bill (Figure 1). Instead of placing a moratorium on implementation of the rules, the recently released Senate reconciliation language would prohibit nearly all of the provisions in the rules from ever being implemented.

Dual-eligible individuals have low incomes and modest savings. The 1.3 million people that would no longer have Medicaid if the eligibility and enrollment rules were not implemented would retain their primary health insurance coverage under Medicare, but lose Medicaid coverage of Medicare premiums, and in most cases, cost sharing, which are provided through Medicare Savings Programs (MSPs) administered by state Medicaid programs. Many would also lose coverage of Medicaid benefits that supplement their Medicare coverage, such as long-term care, dental services, and non-emergency medical transportation.

The loss of Medicaid coverage for Medicare beneficiaries stems from provisions in the House bill that would delay implementation of two Biden administration rules until 2035. The two rules that would be delayed under the House reconciliation bill were intended to make it easier for people to enroll in and maintain Medicaid coverage by minimizing administrative burden in the following ways.

One rule aimed to reduce barriers to enrollment in the Medicare Savings Programs (MSPs), under which Medicaid pays Medicare premiums, and in most cases, cost sharing for low-income Medicare beneficiaries. Among other changes, the rule would automatically enroll Medicare beneficiaries with Supplemental Security Income (SSI) into the MSPs and would more closely align the MSP application to the application for Medicare’s Part D prescription drug Low-Income Subsidy (LIS).

The second rule would more broadly streamline application, enrollment, and renewal processes in Medicaid. Among the changes most relevant for dual-eligible individuals are new requirements for states to assist applicants with procuring appropriate documentation to validate income and assets, a requirement to renew Medicaid coverage only once per year, and a prohibition on requiring in-person interviews as part of the application process

CBO estimates that delaying these two rules would reduce federal spending by $167 billion over 10 years, making this the second largest source of cuts to federal Medicaid spending in the bill. Illustrating why administrative burdens may make it hard for dual-eligible individuals to maintain Medicaid, prior KFF research finds that among people who newly become eligible for both Medicare and Medicaid, 28% lose Medicaid coverage within the first year despite living on fixed incomes.

Although states have already implemented some of the rules’ provisions (Table 1), if the rules are delayed, it is expected that further implementation will cease and states may resume some practices that were prohibited under the rules. For example, 38 states report sending pre-populated renewal forms to Medicaid enrollees who qualify because they are ages 65 and older or have a disability, a practice they may discontinue if the rules are delayed. Alternatively, it’s possible that some states will reinstate requirements for applicants to submit paper documentation or report for in-person interviews. In a few cases, states will be required to reinstate application requirements or be prohibited from using more streamlined application processes.

Losing Medicaid coverage would substantially increase out-of-pocket costs for low-income Medicare beneficiaries. Because Medicare beneficiaries who qualify for Medicaid typically have very low incomes and little to no savings, the loss of Medicaid payment for the costs of Medicare’s premiums and cost sharing could make their Medicare coverage unaffordable. For example, the first rule would automatically enroll low-income Medicare beneficiaries who receive Supplemental Security Income (SSI) into a MSP. Without the MSP, such people must pay 20% of the $967 SSI monthly benefits for the $185 Medicare Part B monthly premium in 2025. (In order to qualify for SSI, individuals must have low incomes, limited assets, and either be over age 64 or have a qualifying disability.) This same individual would have additional out-of-pocket costs if they went to the doctor or were admitted to the hospital. Those additional out-of-pocket costs could discourage low-income beneficiaries from using health care and is the reason for CBO’s estimate that delaying implementation of the rules would reduce Medicare spending by $11 billion over 10 years.

Additionally, some of the 1.3 million Medicare beneficiaries expected to lose Medicaid under the House reconciliation bill may also lose subsidies that help pay for prescription drug premiums and cost sharing. Medicare beneficiaries with Medicaid are automatically enrolled in the Medicare Part D Low-Income Subsidy (LIS), which provides assistance with Part D prescription drug premiums and cost sharing. Illustrating the connection between Medicaid enrollment and LIS coverage, between December 2024 and January 2025, the number of LIS recipients decreased by 1 million, following Medicaid disenrollments that stemmed from the unwinding of the Medicaid continuous enrollment provision. Before the decline, LIS enrollment had been slowly but steadily growing over time.