Coverage Losses by State Under the Graham-Cassidy Bill to Repeal the ACA
Senate Republicans are attempting to rally support for one last try at repealing major portions of the Affordable Care Act (ACA). The latest incarnation of ACA repeal is a bill championed by Sens. Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI). Like the ACA repeal bills considered by the House and Senate earlier this year, Graham-Cassidy would slash the ACA programs that expanded health coverage to millions, weaken consumer protections for people with pre-existing conditions, as well as limit federal support for Medicaid coverage for low-income adults and children, the elderly, and the disabled.
Only 10 days remain for Senate Republicans to pass a bill with only 51 votes via the budget reconciliation process. Rushing Graham-Cassidy through at breakneck speed, Senate leadership is violating customary legislative procedure. Next week, the Finance Committee will hold the Senate’s sole hearing for a bill that would spend a trillion dollars and threaten coverage for millions of Americans. The Congressional Budget Office (CBO) said it will not have sufficient time to produce a comprehensive score of the bill that would show its impacts on coverage and premiums.
If a CBO score of the bill’s impacts in 2027 were available, it would likely show that tens of millions fewer people would have health insurance coverage that year compared to under the ACA. Over the next decade, Graham-Cassidy bill would weaken protections for people with pre-existing conditions, reverse policies that stabilize health insurance markets, and convert the ACA subsidies for Medicaid, the marketplaces, and the Basic Health Program (BHP) into a block grant.
In 2027, the Graham-Cassidy block grant disappears altogether, creating a cliff that drops funding of those subsidies to states and consumers down to zero. One analysis predicts that federal funding to states for health coverage would fall by $299 billion that year relative to what it would be under the ACA.
Graham-Cassidy’s impact on coverage in 2027 would be similar to that of the Obamacare Repeal Reconciliation Act (ORRA), the so-called “repeal and delay” bill that the Senate failed to pass in July. Under both the ORRA and Graham-Cassidy, these three major policies would be in effect a decade from now:
- Repeal of the mandates for individuals to obtain health insurance coverage and large employers to offer insurance
- Elimination of subsidies for nongroup health insurance
- Elimination federal funding for the ACA’s Medicaid expansion
The CBO estimated that the ORRA would have resulted in tens of million more uninsured in 2026. It projects that Medicaid would cover 19 million fewer people and that the individual market, with 23 million fewer people, would nearly disappear. Although the CBO expects that about 11 million more people would have coverage through an employer, the ORRA’s net effect would be 32 million fewer people with coverage in 2026.
It’s likely that the coverage losses resulting from Graham-Cassidy in 2027 could be even larger than the 32 million from the ORRA. Graham-Cassidy not only completely eliminates ACA coverage funding in 2027 but also makes cuts to the Medicaid program outside the ACA expansion. Like many of the ACA repeal bills Congress considered earlier this year, Graham-Cassidy would end the federal government’s guarantee of matching funds to states and restrict funding for each of the major, pre-ACA Medicaid eligibility categories—elderly, disabled, children, and nondisabled adults—under a per capita cap.
Under capped funding, states that experience faster Medicaid cost growth, whether due to natural disasters, health crises, or economic or demographic trends, would no longer see their federal assistance grow accordingly. Simulations using historical data demonstrate that the stricter the per capita cap, the more states are likely to face budget shortfalls. Most worryingly, starting in the year 2025, Graham-Cassidy would limit increases in Medicaid funds for children and nondisabled adults even further to the rate of inflation for consumer goods overall, despite the fact that medical costs are expected to grow more quickly.
Senators will not see a full CBO assessment of Graham-Cassidy before any reconciliation vote, but they should not feign ignorance of the bill’s devastating consequences. Like the other repeal bills this year, Graham-Cassidy’s main features are cuts to premium subsidies, limits on Medicaid funding, and the lifting of protections for people with pre-existing conditions. Those other bills were projected to increase the number of uninsured by tens of millions, and there’s no reason to believe that Graham-Cassidy would be any different.
Emily R. Gee is the health economist for the Health Policy team at the Center for American Progress.
Our state-level estimates show a set of coverage reductions that could result from Graham-Cassidy’s elimination of ACA coverage funding in 2027. We derived our estimates from the CBO’s projected national net effects of the ORRA on coverage in 2026; state data on Medicaid from the Kaiser Family Foundation; and administrative data on individual market enrollment from the Centers for Medicare & Medicaid Services (CMS).
The CBO score of the ORRA included net changes in enrollment by coverage type. The CBO projected that a total 19 million fewer people would have Medicaid coverage by 2026 under the ORRA. We divided that total among states according to their current Medicaid enrollment and the expansion-eligible population in the coverage gap. In the individual market, 23 million fewer people would be enrolled a decade from now under ORRA. We distributed these coverage reductions among states relative to current enrollment in the marketplaces.
The CBO projects that the ORRA would cause a 1 million net reduction in “other coverage,” including the ACA’s BHP. We split the 1 million reduction between the two states that currently offer BHP plans—Minnesota and New York—proportional to their current BHP enrollment.
We expect that a small portion of the people who would have had public or individual market coverage under the ACA in 2027 would instead obtain coverage through the workplace under Graham-Cassidy. The CBO expected that the ORRA would increase enrollment in employer-sponsored coverage by 11 million in 2026. For our estimates, we assumed that each state’s net increase in employer-sponsored coverage was proportional to the sum of its reduction in coverage through nongroup plans, the BHP, and Medicaid.
The Graham-Cassidy net coverage reductions for 2027 shown in Table 1 represent the combined effect of the coverage reductions in Medicaid, nongroup, and the BHP together with the gains in employer-sponsored coverage. Our estimates do not include any effects from Graham-Cassidy’s per capita cap on Medicaid funding for the elderly, disabled, children, and nondisabled adults, which could potentially result in millions fewer with Medicaid coverage.
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Vice President and Coordinator for Health Policy