Note: KFF’s analysis was updated on June 6 to reflect new estimates from the Congressional Budget Office (CBO) on the increase in the number of people who would be without health insurance because of changes to Medicaid and the ACA in the One Big Beautiful Bill Act.

House Republicans have passed a reconciliation package (the “One Big Beautiful Bill Act”) that would make significant changes to Medicaid and the Affordable Care Act (ACA) Marketplaces. The Congressional Budget Office (CBO) estimates that the bill would increase the number of people without health insurance by 10.9 million, because of changes to Medicaid and the ACA. Additionally, these legislative changes come at a time when enhanced premium tax credits for ACA Marketplace enrollees are set to expire later this year. When combining the reconciliation bill’s effects with that of the expected expiration of the ACA’s enhanced premium tax credits, CBO expects 16.0 million more people will be uninsured in 2034 than would otherwise be the case.

This analysis apportions the increase in the number of uninsured across the 50 states and the District of Columbia and shows that number as a percentage of each state’s population. The number of newly uninsured as a percent of the population is equivalent to the percentage point increase in the 2034 uninsured rate. Nationally, CBO projected an uninsured rate of under 10% in 2034 under current law, which assumed the enhanced ACA premium tax credits would expire. The analysis here includes two maps: one showing the effects of the House reconciliation package, and another showing those effects combined with expiration of the ACA enhanced premium tax credits and full impact of the program integrity rule.

Anticipating how states will respond to changes in Medicaid policy is a major source of uncertainty in CBO’s cost estimates. Instead of making state-by-state predictions about policy responses, CBO estimates the percentage of the affected population that lives in states with different types of policy responses. For example, in the reconciliation bill, Medicaid work requirements account for nearly half of the federal savings on Medicaid, suggesting they may contribute to the largest loss of insurance coverage in CBO’s estimates. However, different states might choose to implement a work requirement with reporting requirements that are easier or harder for enrollees to comply with. Reflecting the uncertainty, this analysis illustrates the potential variation by showing a range of enrollment effects in each state, varying by plus or minus 25% from a midpoint estimate.

The interactive table at the end is sortable by state and size of coverage loss.

The One Big Beautiful Bill Act would result in increases in the uninsured rates of 3 percentage points or more in 16 states (Washington, Oregon, Louisiana, New York, Kentucky, Florida, California, Illinois, New Mexico, Rhode Island, Connecticut, Arizona, New Jersey, West Virginia, Arkansas and Alaska) and District of Columbia. These increases are attributable to the One Big Beautiful Bill Act alone and do not include the effect of the expiration of the enhanced premium tax credits nor the full impact of the proposed Marketplace integrity rule.

In terms of increases in the number of uninsured people, California and Florida are the top two states (1.7M and 990k, respectively). New York, Texas, and Illinois would follow at 920K, 770k, and 500k, respectively.

The combined effects of the House reconciliation package with the expiration of the ACA enhanced tax credits, compared to a scenario where the enhanced subsidies are in place and the proposed integrity rule was not in effect, results in the greatest uninsured increases in Florida, Georgia, Louisiana, Texas, Mississippi, Washington, and the District of Columbia, where the uninsured rate is expected to increase by at least 5 percentage points. Thirty-five states and the District of Columbia may see an increase in their uninsured rates of 3 percentage points or more.

About half (48%) of the 16 million more people who would be uninsured in this scenario live in Florida (2.3M), Texas (1.9M), California (1.8M), New York (920k), and Georgia (750k). The largest growth in ACA Marketplace enrollment since 2020, the year before the enhanced premium tax credits became available, occurred in Texas (2.8M), Florida (2.8M), and Georgia (1.0M).

Nearly 200,000 Michiganders could lose Medicaid coverage under work requirements proposed by congressional Republicans this week, even though most are already working or qualify for an exemption.

That’s according to a recent analysis by the Urban Institute , which found that nationally, nearly 9 in 10 adults ages 19 to 64 with Medicaid expansion coverage “already work, are looking for a job, attend school, are caring for family members, are in fair or poor health, or reported having a disability.”

Instead, many would lose coverage simply because they’d fail to properly navigate the reporting requirements, said Katherine Hempstead, a senior policy officer at the Robert Wood Johnson Foundation.

“The way it makes money is when people are not able to comply with the clunky, kludgy system that every state sets up for people to report their hours,” she said. “And then they lose their coverage, even though the vast majority of people that will lose their coverage are actually eligible, because they are working or doing some other exempt activity.”

The estimates of the numbers of people who could lose coverage are roughly in line with what Michigan Department of Health and Human Services is predicting .

“Sixty percent of people in the Healthy Michigan plan are already working, students, or homemakers, and many others are medically frail,” Meghan Groen, senior deputy director at the health department, said in a briefing last week .

“It’s estimated that between 100,000 and 290,000 beneficiaries would lose coverage in the first year, and that’s if work requirements apply only to the expansion population,” Groen said.

But Trump administration officials, and leading congressional Republicans, argue Medicaid work requirements are common sense. “The increased share of welfare spending dedicated to able-bodied working-age adults distracts from what should be the focus of these programs: the truly needy,” Robert F. Kennedy Jr., Mehmet Oz, Brooke Rollins and Scott Turner wrote in a New York Times op-ed on Wednesday.

And the Congressional Budget Office estimates the proposed work requirements alone would also save the federal government $30 billion in the first year alone, according to a KFF analysis .

What work requirements are being proposed?

The most recent version of the work requirement proposal this week required adults age 19 to 64 to be able to show they worked 80 hours a month, Hempstead said, though there would be exemptions.

People could show they had “some kind of work, or acceptable work substitute, such as attending school or job training or volunteering or something else,” she said. “Or they may be able to show that they’re exempt from that requirement because they have a caregiving responsibility to a child or to maybe a parent or some other like disabled relative. Or there will be some exemptions for people who have physical or mental health issues that keep them from working.”

But the details are still being hammered out, including the proposed start date, with some Republicans pushing congressional leaders to move up the initial 2029 timeline, according to The Hill .

Michigan expanded its Medicaid program in 2014, creating the Healthy Michigan Plan, which currently covers more than 700,000 residents. The expansion program covers adults 19 to 64 years old, “incomes up to 133% of the federal poverty level, [who] do not qualify for Medicare or traditional Medicaid, and meet Michigan residency and Medicaid citizenship requirements,” according to a recent state health department analysis.

In 2018, then-Governor Rick Snyder signed a law creating Medicaid work requirements, which was expected to cost “nearly $70 million in administrative funds,” according to the health department. But in 2020, a federal judge ruled the work requirements were illegal. By that point, “more than $30 million was spent on IT system upgrades, staff training, and beneficiary outreach,” according to the state.

Today, state health officials estimate Medicaid work requirements for Healthy Michigan recipients would cost the state about $75 million in administrative costs. But the state could also experience broader impacts, from a rise in uncompensated care, where physicians provide health care that winds up going unpaid, to strain on rural hospitals that primarily serve Medicaid patients. There could also be a drop in the number of children covered by Medicaid, if parents who lose coverage are less likely to enroll their kids.

“Research shows that Medicaid coverage for children is associated with improved health outcomes, higher educational attainment, increased future earnings, and greater tax contributions. The loss of these long-term benefits would represent a significant setback, both for the individuals affected and the state as a whole,” the state’s analysis concluded.

Politics & Government How GOP Bill With $800B Cuts Could Affect MI Medicaid Recipients The Michigan Department of Health and Human Services warned the cuts will affect Michigan families and businesses.

A majority of Michigan’s Medicaid funding – roughly 70 percent – comes from the federal government, officials said. (Shutterstock)

MICHIGAN —House Republicans have unveiled the cost-saving centerpiece of President Donald Trump’s “big, beautiful bill” that could have a big effect on Michigan’s 2.6 Medicaid enrollees.

The legislation unveiled Sunday calls for at least $880 billion in cuts — largely to Medicaid to help cover the cost of $4.5 trillion in tax breaks. The proposal is touching off the biggest political fight over health care since Republicans tried but failed to repeal and replace the Affordable Care Act during Trump’s first term in 2017. Central to the savings are changes to Medicaid, which provides almost free health care to more than 70 million Americans, and the Affordable Care Act, which has expanded in the 15 years since it was first approved.

Republicans insist new work and eligibility requirements are needed to root out “waste, fraud and abuse,” but Democrats warn millions of Americans will lose their health care coverage. The nonpartisan Congressional Budget Office said in a preliminary estimate that 8.6 million people would lose their health care coverage over a decade. Republicans are planning around-the-clock hearings this week on various sections to meet House Speaker Mike Johnson’s Memorial Day deadline to pass the bill.

“Savings like these allow us to use this bill to renew the Trump tax cuts and keep Republicans’ promise to hardworking middle-class families,” said Rep. Brett Guthrie of Kentucky, the GOP chairman of the Energy and Commerce Committee, which handles health care spending. Democrats said the cuts are “shameful” and essentially amount to another attempt to repeal Obamacare.

“In no uncertain terms, millions of Americans will lose their health care coverage,” said Rep. Frank Pallone of New Jersey, the top Democrat on the panel. “Hospitals will close, seniors will not be able to access the care they need, and premiums will rise for millions of people if this bill passes.” The Michigan Department of Health and Human Services warned the cuts will affect Michigan families and businesses.

“These cuts will impact health care services for all Michigan families – whether they have Medicaid or commercial insurance – and small town and rural communities are likely to be disproportionally affected through the loss of hospitals and providers,” said MDHHS Director Elizabeth Hertel. “Studies show a lack of access to health care can lead to higher mortality rates, worse health outcomes, increased health disparities and strain the state’s emergency care system.” Health officials went on to say that Medicaid serves a central role in Michigan’s health care system. It provides comprehensive coverage to more than 2.6 million Michigan residents through over 200,000 Medicaid-enrolled providers. The program is jointly funded by the state and the federal government. Michigan’s Fiscal Year 2025 Medicaid budget is roughly $27.8 billion. A majority of the funding — around 70 percent, or $19 billion – comes from the federal government, officials said. According to data from KFF, Medicaid and CHIP (Children’s Health Insurance Program), of Medicaid recipients nationwide: 82 percent are children living below the poverty level;

62 percent are people living in nursing homes;

41 percent are pregnant women giving birth;

39 percent are children;

31 percent are non-elderly adults with disabilities;

19 percent are Medicare recipients. The politics ahead are uncertain. More than a dozen House Republicans have told Johnson and GOP leaders they will not support cuts to the health care safety net programs that residents back home depend on. Trump himself has shied away from a repeat of his first term, vowing there will be no cuts to Medicaid.

Medicaid is a valued safety net program, according to a recent KFF poll that showed 77 percent of Americans and 84 percent of Medicaid recipients view it favorably. Nearly half (46 percent) and two-thirds of Medicaid enrollees believe the federal government isn’t spending enough on the program, according to the poll. To be eligible for Medicaid, there would be new “community engagement requirements” of at least 80 hours per month of work, education or service for able-bodied adults without dependents. People would also have to verify their eligibility to be in the program twice a year, rather than just once. This is likely to lead to more churn in the program and present hurdles for people to stay covered, especially if they have to drive far to a local benefits office to verify their income in person. But Republicans say it’ll ensure that the program is administered to those who qualify for it. Many states have expanded their Medicaid rosters thanks to federal incentives, but the legislation would cut a 5 percent boost that was put in place during the COVID-19 pandemic. Federal funding to the states for immigrants who have not shown proof of citizenship would be prohibited. There would be a freeze on the so-called provider tax that some states use to help pay for large portions of their Medicaid programs. The extra tax often leads to higher payments from the federal government, which critics say is a loophole that creates abuse in the system.