Last month, House Republicans passed a tax and budget reconciliation bill that, if enacted, would lead to 16 million people becoming uninsured while dramatically increasing health care costs for millions of working families. These changes would affect Americans with various types of health insurance by driving up premiums and out-of-pocket spending for millions of people with Affordable Care Act (ACA) marketplace plans, squeezing many low-income families on Medicaid, and increasing out-of-pocket limits for some people with job-based coverage. Despite promises to protect Medicare, House Republicans’ One Big Beautiful Bill Act also takes direct aim at low-income seniors by making it harder for 1.3 million Medicare enrollees to access federal programs that would help them afford their health care costs, including for prescription drugs.
A new analysis by the Center for American Progress makes clear just how harsh these policies would be for working families across insurance types:
- Medicaid: A family of four on Medicaid making $33,000 per year could face up to $1,650 in new annual out-of-pocket spending.
- ACA marketplaces: A 60-year-old couple making $85,000 per year who hope to stay on their same marketplace plan would see their annual premium costs skyrocket by $15,400, from about $6,900 to about $22,300. Should that couple try to save money by buying a lower-value plan, they would still have to pay more than $12,600 in additional premium expenses.
- Medicare: Despite President Donald Trump’s repeated promises not to cut Medicare, Medicare enrollees with low incomes would be hit hardest of all. An older couple on Medicare living on an annual income of only $21,000 could face an additional $8,340 in health care costs each year as a result of the House-passed bill.
- Job-based health insurance: A family with job-based health insurance could face up to $900 more in annual spending as their out-of-pocket maximums increase.
TABLE 1
Costs would soar for many working families on Medicaid who lose coverage
Medicaid is a lifeline for the more than 71 million low-income Americans enrolled in the program. Yet the nonpartisan Congressional Budget Office (CBO) estimates that 7.8 million Medicaid enrollees would become uninsured if the House-passed bill becomes law. The bill’s burdensome work reporting requirements on Medicaid expansion enrollees—adults with incomes up to 138 percent of the federal poverty level (FPL) who qualify for the program based on income alone—would cause the bulk of those coverage losses. The CBO projects that 4.8 million more people would be uninsured as a result.
Data consistently show that nearly all adult Medicaid enrollees (92 percent) are already working, are in school, or are not working due to illness or caregiving. Accordingly, evidence from Arkansas, which implemented Medicaid work reporting requirements in 2018, demonstrates that such requirements primarily serve to kick eligible people off coverage. This happens because of burdensome red tape, not failure to meet reporting requirements.
The House Republican budget bill would apply similarly burdensome reporting rules to Medicaid expansion adults across the United States, which would lead to eligible people losing coverage. While some individuals would qualify for exemptions, state experiences show that even Medicaid enrollees who are exempt would likely lose coverage due to confusion, administrative errors, or failure to navigate complex paperwork. For example, a person could lose Medicaid coverage entirely because an address change made keeping up with paperwork impossible or because their work hours were cut—outside of their control—in any given month. Due to these requirements, the bill would then allow states to bar people who were disenrolled from reenrolling for at least three months and from receiving premium tax credits to purchase coverage through the ACA marketplaces.
Losing coverage does not make an illness disappear. Extrapolating from a 2017 Commonwealth Fund study by Sherry Glied, Ougni Chakraborty, and Therese Russo on changes in out-of-pocket costs for people gaining coverage as a result of Medicaid expansion, CAP estimates that adults who lose Medicaid coverage would spend an average of about $2,220 more in annual out-of-pocket costs. This cost burden could force low-income families to delay care or take on crippling debt. For example, a couple with an annual income of $22,000—or 104 percent of the FPL—who lost Medicaid could face $4,440 more in out-of-pocket costs, constituting about 20 percent of their income.
New mandatory Medicaid out-of-pocket costs would strain family budgets
Even Medicaid expansion adults who successfully complete work reporting paperwork to maintain their coverage would see significant out-of-pocket cost increases because of the House Republican budget bill. For the first time, state Medicaid programs would be required to impose cost-sharing for certain health care services for enrollees with incomes at or above 100 percent of the FPL, capped at 5 percent of their annual household income. Section 44142 of the bill would also allow providers to turn away patients who can’t afford to pay those costs.
$1,650
Amount a Medicaid expansion enrollee in a family of four might have to pay in out-of-pocket expenses each year under the One Big Beautiful Bill Act
If the bill becomes law, a Medicaid expansion enrollee in a family of four with an annual income of $33,000, or about 103 percent of the FPL, could face up to $1,650 in out-of-pocket expenses each year—constituting 5 percent of their income. For poor families living paycheck to paycheck, this added financial strain could result in skipping necessary care or falling into medical debt. Studies consistently show that even modest fees cause people to forgo doctor visits, delay treatments, and stop taking medications.
Many working families with ACA marketplace coverage would face thousands more in premiums and out-of-pocket costs
The House Republican-passed budget bill includes a number of provisions that would make ACA marketplace plans more expensive and less accessible for millions of families across the country who buy coverage on their own. In addition to codifying changes that would make it harder to enroll in marketplace plans—such as shortening the annual open enrollment period and eliminating the year-round special enrollment period for people with family incomes up to 150 percent of the FPL—the bill would raise premiums by eliminating plans’ practice of “silver loading.” Furthermore, the bill fails to extend the enhanced premium tax credits currently set to expire after 2025, even as it prioritizes extending expensive tax breaks that overwhelmingly benefit the wealthiest Americans.
Enhanced premium tax credits—first enacted under the American Rescue Plan and later extended in the Inflation Reduction Act—have significantly lowered marketplace premiums for millions of Americans. They made the ACA’s premium tax credits more generous and extended eligibility for tax credits to families with incomes above 400 percent of the FPL by capping premium expenses at no more than 8.5 percent of annual household income. Notably, when passing their budget bill, House Republicans voted down an amendment that would have extended those enhancements beyond December 2025. Should the enhanced ACA premium tax credits expire, the CBO projects that 4.2 million people would become uninsured as a result.
The bill’s changes to “silver loading” would only compound this harm. Marketplace plans’ practice of silver loading began in 2018 after the first Trump administration stopped reimbursing insurers for cost-sharing reductions—the financial assistance that lowers out-of-pocket costs such as deductibles and copays for silver-tier plans for enrollees with family incomes between 100 and 250 percent of the FPL. The ACA requires that insurers provide cost-sharing reductions to eligible enrollees, so, in most states, plans “loaded” them onto the premiums of silver-tier plans to cover the cost. Because premium tax credits are tied to the price of the second-lowest-cost silver plans, as the costs of those plans went up, so did the premium tax credits. This allowed many people to access free, high-deductible bronze plans or to spend less money purchasing higher-value—and lower-deductible—gold plans. By reversing silver loading, though, the bill would increase premiums for many people with marketplace coverage. The CBO estimates reversing silver loading alone would cause 300,000 people to become uninsured because coverage would become unaffordable.
A new CAP analysis considers the combined impact that these provisions of the House Republican budget bill would have on marketplace enrollees’ costs. Figure 1 shows how costs would increase for three households: a 60-year-old couple making $85,000 a year (about 402 percent of the FPL) with benchmark silver-tier coverage; a 40-year-old individual making $40,000 (about 256 percent of the FPL) with gold-tier coverage; and a 30-year-old couple making $64,000 (about 303 percent of the FPL) a year with bronze-tier coverage.
FIGURE 1
If the enhanced premium tax credits expired, the 60-year-old couple would no longer be eligible for tax credits at all because their income is above 400 percent of the FPL. In order to keep their coverage, they would need to pay about $15,400—roughly a fifth of their income—more in annual premium costs. If the couple instead chose to save money by buying a more affordable bronze plan, that coverage would still cost them about $12,600 in additional premium expenses.
Meanwhile, the 40-year-old making about $40,000 a year, or about 256 percent of the FPL, with gold-tier coverage would need to pay about $2,300 in additional premium costs per year to keep their plan, as the loss of the enhanced premium tax credit would increase their premium contribution from 4 to 8.05 percent of their annual income. Even downgrading to a more affordable silver-tier plan would cost them an extra $1,500. And that downgrade would come with increased cost-sharing. Specifically, their deductible would rise from $1,450 to $5,000, and their annual out-of-pocket maximum would increase from $7,500 to $8,500.
Lastly, the 30-year-old couple earning $64,000 a year, or about 303 percent of the FPL, and enrolled in a bronze-tier plan would also be hit hard by increases due to the bill. Annual premium costs for their plan would more than triple, rising by more than $3,500. Since bronze plans already have the highest deductibles and expected out-of-pocket costs, the couple would be paying more for coverage that leaves them exposed to what could be catastrophically high medical bills. For young families trying to budget for rent, groceries, and credit card bills, this kind of increase could force impossible trade-offs—skipping care, taking on debt, or going uninsured altogether.
1.3 million Medicare enrollees would see their health care costs surge due to the House-passed bill
The Trump administration has consistently promised to not cut Medicare. Yet the House-passed bill would do exactly that. Specifically, the bill would block implementation of an existing regulation that makes it easier for eligible low-income Medicare beneficiaries to enroll in Medicare Savings Programs (MSPs) that lower Medicare premiums and out-of-pocket costs.
These programs include the Qualified Medicare Beneficiary (QMB) program and the Specified Low-Income Medicare Beneficiary (SLMB) program. The QMB program helps Medicare enrollees with incomes below 100 percent of the FPL and with very limited assets by covering the costs of their Medicare Part A and B premiums and eliminating most out-of-pocket costs for Medicare-covered services. It effectively turns Medicare into a zero-cost program for the poorest enrollees. The SLMB program provides more limited help to Medicare enrollees with incomes between 100 and 120 percent of the FPL by covering their monthly Part B premiums.
FIGURE 2
Together, these programs make health care accessible for Medicare enrollees, who often live on very limited incomes and few assets. Without enrolling in the programs, even modest medical bills can be unaffordable, and basic access to care can slip out of reach. Blocking the regulation would prevent states from streamlining and automating enrollment into MSPs. As a result, the CBO estimates that the House Republican budget bill would cause 1.3 million Medicare enrollees who would be eligible for these programs through dual enrollment in Medicaid to lose or forgo their Medicaid coverage and therefore be unable to access the assistance.
Consider the following example of a QMB-eligible beneficiary. For a 65-year-old couple with Medicare coverage and a combined income of $21,000 per year, not having access to the QMB program would mean being on the hook for $4,440 annually in Medicare Part B premiums. If one person were hospitalized, they would face a $1,676 deductible under Medicare Part A that would otherwise have been paid for. If that hospitalization were serious and their stay extended beyond two months, they would owe $419 per day for the third month and $838 per day for the fourth month. A rehabilitative stay in a skilled nursing facility after leaving the hospital could cost them about $210 per day after just three weeks. These costs would all have been covered by the QMB program.
QMB enrollees automatically qualify for the Medicare Part D Low-Income Subsidy (LIS) program, also known as “Extra Help,” which caps prescription drug cost-sharing at $4.90 for generic drugs and $12.15 for brand-name drugs. Medicare enrollees on the Extra Help program projected to meet Medicare Part D’s annual out-of-pocket maximum—$2,100 in 2026—will save an average of about $1,100 on drug costs.
Yet CAP estimates that if the House Republican-passed budget bill becomes law, the QMB-eligible couple described above would incur great costs. In fact, just one hospital stay in a year, accounting for the full cost of Extra Help and Medicare Part B premiums, could amount to $8,340 in additional out-of-pocket costs—assuming one hospitalization and the couple reaching their annual out-of-pocket maximum for Part D prescription drug spending. This amounts to almost 40 percent of the couple’s annual income.
An SLMB-eligible beneficiary could also see thousands in higher costs. For a Medicare enrollee making $19,000 per year, out-of-pocket costs could increase by $2,200 per year for Part B premiums if they’re unable to access the SLMB program due to changes in the House-passed tax and budget bill. As with QMB enrollees, SLMB enrollees also qualify for Medicare’s Extra Help benefit. That means this beneficiary could be on the hook for a total of about $3,300 in additional costs per year—or about 18 percent of their annual income–in out-of-pocket prescription drug spending.
People with job-based coverage could see their out-of-pocket costs climb by close to a thousand dollars each year
Some families with private coverage, including those with job-based coverage, would see their annual out-of-pocket costs climb by hundreds of dollars as a result of policy changes included in the House Republican budget bill. The bill codifies a Trump administration rule that would leave marketplace enrollees worse off, including by allowing insurers to offer plans with lower actuarial values so that enrollees would have higher deductibles and out-of-pocket costs.
The administration’s rule would also change a formula used to update annual limits for out-of-pocket costs for nearly all forms of private coverage. As a result, people enrolled in private insurance through their jobs may need to spend more before being protected by their plan’s out-of-pocket maximum. According to a Center for Budget and Policy Priorities (CBPP) analysis, this change would mean that a person with job-based coverage could have their out-of-pocket maximum increase by $450, and a family with job-based coverage could see their out-of-pocket maximum increase by $900.
See also
Conclusion
The House Republican-passed tax and budget reconciliation bill would increase health care costs for many Americans with Medicaid, Medicare, ACA marketplace plans, and job-based insurance. Individuals and families could face steep increases in premiums, deductibles, and other out-of-pocket expenses, amounting to thousands of dollars per year.
The authors thank Christen Linke-Young, Sherry Glied, Dong Ding, Gideon Lukens, Emily Gee, and Natasha Murphy for their support with this piece, as well as Natalie Baker, Aurelia Glass, Mimla Wardak, and Amina Khalique for their fact-checking assistance.
Methodology
Medicaid
To estimate out-of-pocket costs for a couple losing Medicaid and becoming uninsured, the authors used a 2017 Commonwealth Fund study by Sherry Glied, Ougni Chakraborty, and Therese Russo, which found that Medicaid expansion reduced out-of-pocket spending by $382 for all families and $2,938 for newly enrolled, previously uninsured families. CAP assumed that the out-of-pocket savings for someone gaining Medicaid coverage would be symmetric to the out-of-pocket costs faced by someone losing Medicaid coverage. Dividing $2,938 by the average U.S. family size of 1.7—used in the 2017 Commonwealth Fund analysis and communicated to CAP via email on June 10, 2025—yielded roughly $1,729 per person. Adjusted for medical inflation, that amount would be $2,220 in 2025 dollars. The authors then multiplied the amount by 2 to reflect a couple and divided that amount by their annual income to calculate the total additional health costs as a share of income.
To estimate out-of-pocket costs for a Medicaid expansion enrollee in a family of four subject to new mandatory cost-sharing, the authors assumed the enrollee would be responsible for copays totaling 5 percent of their annual family income, the maximum allowed percentage in the bill. The authors divided that amount by the enrollee’s annual family income to calculate the total additional costs as a share of income.
ACA marketplaces
To calculate the impacts of the expiration of enhanced premium tax credits (PTCs) and silver-loading reversal on ACA marketplace premiums, the authors started with KFF’s national average marketplace premiums by metal tier, then adjusted for the appropriate age for the person in each scenario. To estimate premiums after the silver-loading reversal, the authors deflated benchmark silver-plan premiums by 12.2 percent, per the CBO’s latest projections, while keeping bronze- and gold-plan premiums unchanged. Finally, the authors factored in the expiration of enhanced PTCs by reverting to the ACA’s original PTC formula, which increased the net premiums after subsidy. Given the uncertainties around marketplace premium growth in 2026 due to pending marketplace policy changes, the authors did not index 2014 premium caps to a future year. As a result, premium cost estimates in this column are likely conservative.
For the impacts of changing metal tiers, the authors used data from a 2022 Commonwealth Fund study that calculated median deductibles and out-of-pocket limits by tier.
For each example household, the authors combined all the additional health costs, then divided the total by annual income to determine the overall increase in health expenses as a share of income.
Medicare
To calculate additional costs for Medicare enrollees, the authors estimated the total extra spending for a QMB-eligible couple not enrolled in the program, including Part B premiums and a hypothetical hospital stay deductible. The authors also accounted for the value of the LIS program, as QMB beneficiaries automatically qualify for LIS. The analysis used the difference in projected out-of-pocket costs at the maximum limit between non-LIS enrollees and LIS Medicare enrollees to represent the estimated value of LIS. For SLMB-eligible Medicare enrollees, the authors followed the same approach but excluded the hospital stay costs—which are not covered by SLMB—while still accounting for lost LIS benefits.
The authors combined the additional health costs for each household, then divided the total by annual income to determine the overall increase in health expenses as a share of income.
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