GOP lawmakers in the 10 states that rejected the Affordable Care Act’s (ACA) Medicaid expansion for over a decade have argued that their conservative approach to expanding government programs would be beneficial in the long run, Daniel Chang and Sam Whitehead wrote on August 8 for KFF Health News. Instead, they reported, hospital executives warn that “the Republican-passed budget law that includes many of President Donald Trump’s priorities will pose at least as big a burden on patients and hospitals in the expansion holdout states as in the 40 states that have extended Medicaid coverage to more low-income adults.”
Georgia, with just over 11 million residents, will see as many people losing insurance coverage through ACA marketplaces as California, which has more than triple its population, according to estimates by KFF. The new law adds extra paperwork requirements for Obamacare enrollees, reduces the time they have each year to sign up, and cuts funding for navigators who assist them in finding plans. These changes, all of which will decrease enrollment, are expected to have a greater impact in states like Florida and Texas than in California because a higher percentage of residents in non-expansion states are enrolled in ACA plans, Chang and Whitehead wrote.
The budget law will bring major changes to healthcare nationwide as it reduces federal Medicaid spending by over $1 trillion over the next decade. The program serves more than 71 million low-income and disabled individuals. Due to the law, ten million people will lose coverage over the next decade, according to the nonpartisan Congressional Budget Office (CBO).
Many of its provisions target the 40 states that expanded Medicaid under the ACA, which brought millions more low-income adults onto the rolls. However, KFF Health News noted, the effects are not limited to those states. A conservative proposal to reduce more generous federal payments for individuals added to Medicaid by the ACA expansion didn’t become law.
Furthermore, the authors noted that the number of people losing coverage could increase in non-expansion states if enhanced federal subsidies for Obamacare plans expire at the end of the year. This could lead to higher premiums starting in January and result in more uninsured individuals. KFF estimated that up to 2.2 million people could become uninsured in Florida alone. In this state, lawmakers refused to expand Medicaid and, partly as a result, now leads the nation in ACA enrollment.
Although GOP lawmakers might attempt to cut Medicaid further this year, Chang and Whitehead wrote, the states that expanded Medicaid mostly seem to have made a wise choice for now. Meanwhile, states that haven’t expanded Medicaid are dealing with similar financial pressures without any clear benefit, according to health policy experts and hospital industry observers.
Enrollment in ACA marketplace plans across the country has more than doubled since 2020 to 24.3 million. If enhanced subsidies end, premiums for Obamacare coverage could increase by more than 75 percent on average, according to an analysis by KFF. Some insurers are already indicating that they plan to hike prices.
“August 13th is the deadline for qualified health plans to submit changes to their filings to the Centers for Medicaid and Medicare Services (CMS) for the Federal marketplace,” Families USA’s executive director, Anthony Wright, recently said during a panel discussion on market insurance rates for 2026. Nineteen states and Washington, DC., have announced proposed rates, with an average increase of over 15 percent.
The CBO estimated that letting enhanced subsidies expire will lead to 4.2 million more people being uninsured by 2034 compared to a permanent extension, KFF Health News’ Chang and Whiteread reported. This would add to the coverage losses caused by Trump’s budget law, the authors noted.
Furthermore, as the uninsured rate increases in non-expansion states and the Medicaid cuts in the budget law approach, lawmakers state that state funds will not compensate for the loss of federal dollars, even in states that have refused to expand Medicaid.
For hospital leaders in other states that have refused full Medicaid expansion, the budget law presents another challenge by restricting financing arrangements that states used to make higher Medicaid payments to doctors and hospitals, KFF Health News’ authors reported.
Starting in 2028, the authors wrote, the law will cut those payments by 10 percentage points annually until they are closer to what Medicare covers.
The budget law allocates a $50 billion fund to protect rural hospitals and clinics from changes to Medicaid and the ACA, the authors noted. However, a KFF analysis found it would cover only about a third of the Medicaid cuts in rural areas.
States like Florida, Georgia, and Mississippi have not only declined the additional federal funding that Medicaid expansion offers, Chang and Whitehead noted, but also most of the remaining non-expansion states spend less than the national average per Medicaid enrollee, provide fewer or less generous benefits, and cover fewer categories of low-income Americans.
