Richard Feldman column: 'Big, beautiful bill' brings dark time for American health care

Primarily due to the Affordable Care Act, the United States has made great progress in expanding health insurance coverage.

The uninsured rate is at a historic low of 7.7%. In 2010, it was 16% before the ACA's enactment.

According to federal reports, 45 million people are covered by the ACA, with 24 million through the Health Insurance Marketplace and the remainder through Medicaid expansion for those who previously did not qualify.

The ACA financially enables states to expand their Medicaid programs by providing a federal match that covers 90% of the expansion costs.

Of the 45 million covered, about 21 million gained ACA coverage in 2024 due to newly enacted provisions, including enhanced premium subsidies for individuals below 400% of the federal poverty level.

Assisting low-income individuals in obtaining health insurance is essential. A healthier society is a benefit to all (including businesses and industry) and eliminates cost shifting from the uninsured to those insured.

The progress made in insurance coverage is now threatened by the Trump administration and Congress. The passage of the Budget Reconciliation Act ("The Big, Beautiful Bill") brings significant changes to the ACA and Medicaid, which, according to the Congressional Budget Office, will result in 12 million Americans losing coverage.

In 2017, President Trump and many Republican lawmakers failed to repeal the ACA. They now have the opportunity to roll back many ACA provisions. Maiming the ACA is a priority.

The legislation significantly reduces ACA/Medicaid funding. The enhanced Marketplace premium subsidies sunset at the end of 2025 and will not be renewed. Patient co-payments will be instituted in expanded Medicaid and there will be reductions in the allowed Medicaid provider taxes.

These taxes help cover states' portion of the Medicaid expansion in order to draw down the enhanced federal match.

Medicaid work requirements and escalated scrutiny over eligibility are major focuses. The administration already slashed ACA enrollment outreach by 90%, and Congress contracted enrollment periods.

There will be limitations for Medicare eligibility, limitations for Marketplace premium subsidies for certain legal-status immigrants, and limitations in federal funding for emergency care for the undocumented. Huge reductions in Medicaid funding for long-term care will lead to eligibility restrictions, service cuts and closure of nursing homes.

The Senate version of this bill also proposed increasing certain Marketplace plan premiums and prohibiting Medicaid coverage for many lawfully residing non-citizens such as refugees and immigrants whose statuses are not immediately verifiable.

Additionally, reducing the enhanced 90% federal match for states that cover undocumented immigrants under expanded Medicaid was offered. The parliamentarian ruled these provisions ineligible for inclusion if the Senate wanted to pass the bill with a simple majority rather than the usual 60-vote requirement.

Conceivably, those provisions could be revisited in the future along with additional proposals such as alternative lower-premium insurance plans lacking the ACA's consumer protections (like pre-existing condition coverage); plans with high-risk, high-premium insurance pools; curtailing the enhanced expanded Medicaid match; converting Medicaid financing to state block grants; and an overall cap on federal funding.

Trump does support some positive changes including surprise billing protections, hospital price transparency regulations, and lowering drug pricing.

To extend the 2017 tax cuts and introduce new ones, significant reductions in federal spending were required. Since Trump determined that the big-ticket items of Medicare, Social Security and defense would not be touched, it necessitated putting the ACA and Medicaid on the chopping block.

It's a dark time for American health care.