As Congress weighs a budget reconciliation package that would enact the largest Medicaid cut in the program’s history, Republican leaders—including Speaker of the House Mike Johnson (R-LA) and Energy and Commerce Chair Brett Guthrie (R-KY)—are considering proposals to reduce federal matching funds that support state Medicaid expansion populations.
The Affordable Care Act (ACA) guarantees states an enhanced federal medical assistance percentage (FMAP) of 90 percent to cover Medicaid costs for adults with family incomes up to 138 percent of the federal poverty level—with states covering the remaining 10 percent. This funding structure has enabled 40 states and Washington, D.C., to expand Medicaid and provide coverage for more than 20 million Americans. Shrinking the FMAP would shift significant financial burdens onto states, several of which have laws that trigger automatic rollbacks of Medicaid expansion if federal support declines. States would feel these effects across each of their congressional districts.
Medicaid cuts would cost thousands of lives each year
As the nation’s single-largest health insurance program, Medicaid covers critical health services for nearly 72 million Americans, including low-income individuals; children; older adults; and people with disabilities. Medicaid coverage improves access to preventive care and supports early diagnosis and treatment as well as management of chronic and acute conditions. It also provides enrollees with access to essential maternal health, behavioral health, and long-term care services.
Accordingly, multiple studies have found that Medicaid expansion is associated with significant reductions in mortality. Building on this evidence, a 2021 CAP analysis estimated that expanding Medicaid in all remaining nonexpansion states at that time would have saved at least 7,000 lives each year. Proposals to shrink the FMAP would result in coverage losses and, therefore, have the opposite effect—endangering the health and lives of Americans. A recent CAP analysis found that the FMAP reductions that Republican leadership favors would lead to roughly 34,200 avoidable deaths each year.
FMAP reductions would cost lives
If Congress shrinks the enhanced FMAP and states respond by eliminating their Medicaid expansions in 2026, 15.9 million people would lose their coverage and, as a result, 10.8 million would become uninsured across congressional districts in each Medicaid expansion state, according to estimates from the Urban Institute. A 2017 study by health economist Benjamin D. Sommers found that Medicaid expansion was associated with “one life saved annually for every 239 to 316 adults gaining insurance.”
Applying the more conservative end of Sommers’ range to Urban’s coverage loss projections, CAP estimates that cutting the enhanced FMAP for expansion enrollees would lead to deaths in each congressional district—as many as hundreds in some. For example, each year, 397 avoidable deaths would occur in New York’s 13th Congressional District; 189 avoidable deaths would occur in Louisiana’s 4th Congressional District; and 124 avoidable deaths would occur in Kentucky’s 2nd Congressional District. Table 1 details the estimated deaths by congressional district for each Medicaid expansion state.
Conclusion
Congressional Republicans are considering proposals that would severely undermine the Medicaid program, threatening coverage for millions of Americans. Reduced federal funding would lead to widespread coverage losses and, by conservative estimates, tens of thousands of avoidable deaths each year. In some congressional districts, avoidable deaths could number in the hundreds. This outcome is avoidable, if Congress preserves the current FMAP.