The big beautiful bill and Obamacare

Republicans in Congress have dropped the mantra to "repeal and replace" Obamacare that they repeated so often during President Donald Trump's first term. This time, their "big beautiful bill" would instead undermine the Affordable Care Act in subtle ways.

The legislation would erect multiple barriers to receiving the subsidized ACA coverage at the law's core. It would shorten enrollment periods, restrict access for many immigrants living legally in the country and add burdensome paperwork that would make it hard for people to remain on the plans they already have.

Take, for example, the bill's provision to end automatic re-enrollment in ACA insurance plans. In 2025, nearly 11 million people who bought policies on the state exchanges — about half of all enrollees — were automatically re-enrolled, a practice that is typical across the health insurance industry. The Congressional Budget Office projects that eliminating this for the ACA would result in 700,000 people becoming uninsured by 2034.

The bill also would add a stricter eligibility verification process, requiring beneficiaries to gather documents every year to prove that they remain eligible, based on their income, immigration status and more. Altogether, the CBO estimates, this new red tape would cause more than 3 million people to lose their health insurance.

This is in addition to the 4 million who are expected to lose coverage due to the expiration of enhanced ACA subsidies that Republicans appear likely to allow to lapse. Add in the Medicaid cuts also in the legislation, and the total number of uninsured Americans stands to rise by 16 million. This would wipe out most of the gains in health coverage that the United States has achieved since the ACA was put in place.

And this calculus leaves aside what the bill's ACA policies might doto people's health insurance premiums down the line. Sick people, who have the greatest need for health care coverage, will be the ones most likely to go to the trouble to navigate the bureaucracy, while healthy people might be more inclined to give up. Then, with fewer healthy people in the risk pools, premiums would rise for everyone.

If the bill's proposed ACA requirements were designed to fix some major problem, perhaps some decline in coverage could be justified. But they aren't. Unlike Medicaid, ACA subsidies are not given to people who are not working; to be eligible, beneficiaries must verify that they have an income — for example, by providing a tax return.

And while it is true that the federal ACA marketplace has seen fraudulent enrollments, this is due largely to some health insurance brokers' gaming the system to enroll people in plans without their permission. But officials who run state marketplaces say they don't have this problem, and they insist that it is possible to combat such fraud without hassling people who are trying to keep their health plans. Federal officials, too, have begun making administrative changes to address the problem.

This is not to say that America's health care system is already perfect. It covers too few people, it costs too much, and it's complicated and confusing for people. But the solution is not to make it even more complex so that more people have no insurance at all. What's needed is the opposite: an effort to consolidate public health care programs, to make them easier to understand and more efficient, while acting to lower the cost of health care.

If the legislation were designed to save money this way, it would be worth supporting. But the Obamacare revisions embedded in the Republicans' bill provides no benefits to offset the damage it would do.

An editorial from The Washington Post.