Here's how millions of people could lose health insurance if Trump's tax bill becomes law

WASHINGTON (AP) — Roughly 11.8 million adults and children will be at risk for losing health insurance if Republicans' domestic policy package becomes a law.

The losses won't come all at once. The GOP's “ One Big, Beautiful Bill Act ” makes changes that will whittle away at enrollment through federal health care programs like Medicaid and Obamacare over a decade in order to wrest nearly $1 trillion from Medicaid, the Affordable Care Act, and the Children's Health Insurance Program.

The bill is likely to reverse years of escalating health insurance rates in the U.S., gains that have also been marked by record spending on federally-funded health care coverage. Roughly 78 million adults and children are enrolled in Medicaid's programs while 24 million people are enrolled in the ACA's marketplaces.

Medicaid is a joint federal-state venture that is administered by the states. The program goes by different names in some states, like Medi-Cal in California, BadgerCare in Wisconsin, or MassHealth in Massachusetts.

A look at some of the ways in which people may lose health care coverage under the GOP's plan:

Medicaid or Obamacare enrollee? Your income and eligibility will be checked closely and more often.

<hl2/>

Under the GOP's plan, states will need to verify a person's income to check Medicaid eligibility every six months.

People who are homeless or transient may miss notices from the government to fill out paperwork more frequently, said Martha Santana-Chin, the CEO of L.A. Care Health Plan, which provides Medicaid for millions of Los Angelenos. They'll lose their coverage if they don't respond.

“The life experience of these individuals is not necessarily one that allows them the luxury of having to work through onerous paperwork,” Santana-Chin said.

When Texas increased income eligibility checks between 2014 and 2019, for example, thousands of kids lost coverage in the state. Critics faulted the frequent checks, too, for the state having the highest rate of uninsured children in the nation at the time.

States will also be required to check enrollees’ addresses and death records more frequently.

People enrolled in the ACA's marketplace coverage will also be subject to more scrutiny over their reported income and face penalties if they end up earning more than they expected when signing up for the coverage. They'll have to wait for the government to verify their information, too, before getting coverage.

It will be a sharp contrast from employer-based coverage, where people are re-enrolled every year unless they opt out.

Is your child enrolled in coverage?

States will be allowed to delay kids from enrolling in the Children’s Health Insurance Program in some cases.

They will be allowed to temporarily block parents from enrolling their children if they are behind on paying the premiums for the coverage. Those premiums for kids’ coverage can run as much as $100 a month in some states, according to health policy research firm KFF. States will also be able to introduce a waiting period for kids who are being transitioned from private health insurance plans to Medicaid.

The Biden administration prohibited states from locking out parents from enrolling their kids in coverage over missed payments or a waiting period when transitioning from private health insurance.

Are you an immigrant? Getting coverage may get harder.

The bill narrows the definition of who qualifies for lower Obamacare, restricting access for thousands of refugees and asylum seekers who come to the U.S. every year.

States that offer Medicaid coverage to cover immigrants who may not be here legally will also receive less money from the federal government. Several states allow immigrants to enroll in Medicaid, paid for only using state tax dollars. But the bill threatens that coverage by lowering the rate the federal government pays for all legal residents from 90% to 80%.

That will lead some states to drop their program for immigrants entirely rather than lose federal funding. Already, California has announced a freeze on any new enrollment for the state funded Medi-Cal for all immigrants. Illinois, meanwhile, halted its program this month.

Able-bodied? You’ll have to work, volunteer or go to school.

Most coverage losses are expected to come from the GOP's proposed work requirement. People aged 19 through 64 will be required to work, volunteer or go to school for 80 hours per month in order to qualify for Medicaid under the new law. They'll be exempt if they're disabled, pregnant or parent a child who is 14 or younger.

Ultimately, some people will decide they don't want to work and don't need the coverage, said Michael F. Cannon, director of health policy studies at the libertarian think tank Cato Institute.

“It can encourage people who don’t value Medicaid coverage not to sign up for it,” Cannon said. “And that saves the government money.”

Most Medicaid enrollees already work, attend school, have a disability or are caregivers, which should exempt them from the requirement. Only about 8% of enrollees report not working or being unable to find work.

In some cases, people will lose coverage even if they're working. They will fall victim to bureaucratic errors, overlooked forms, or trouble getting all of the documents — like proof of employment and tax forms — together to prove to the government that they're working. Verifying work will be especially difficult for people who don't have access to the internet, a computer or phones.

That's how some people lost coverage in Arkansas, which tried to enact work requirements in 2018. Roughly 18,000 people were pushed off Medicaid within seven months. A federal judge later blocked the requirement.

Enrolled in both Medicare and Medicaid? It will be harder to apply

Millions of people qualify for both Medicare and Medicaid, often because of a disability.

The GOP bill will roll back requirements of the ways the Biden administration streamlined enrollment for those people, including a rule that required states to automatically enroll people into coverage if they qualify for supplemental income because of a disability.

“By rescinding these rules and no longer requiring states to make some of these simplifications, it’s likely that some people will lose coverage because they get caught up in these paperwork burdens,” said Jennifer Tolbert, director of state health policy at KFF.