Health program cuts hit home, fueling blame game

Sweeping changes that congressional Republicans made to the Affordable Care Act and Medicaid are starting to take effect, fueling an election-year blame game over coverage losses.

Why it matters: A rise in the uninsured rate will put more stress on the health system and ratchet up concerns about health costs in an election year where affordability is voters' biggest concern.

Driving the news: The changes are hitting home, with about 1.2 million fewer people signed up for ACA coverage compared with a year ago, following Congress' refusal to extend enhanced subsidies.

• Nebraska this month also became the first state to impose new work requirements on Medicaid recipients who enrolled under the ACA expansion.

By the numbers: Wakely Consulting Group found that 14% of enrollees did not pay their first ACA premium in January. It estimated that 2026 enrollment will end up being 17% to 26% lower than last year.

• Insurers in some states are reporting drops in enrollment as high as 20% to 30%, while other states are stepping in to offer additional financial help to limit the losses, according to an insurance industry source.

What they're saying: "We don't have full data yet but all signs point to a substantial drop in enrollment with the expiration of the enhanced premium subsidies," said Larry Levitt, executive vice president for health policy at KFF, estimating "several million" fewer enrollees.

The coverage losses already are seeping into campaign messaging ahead of the midterm elections as Democrats try to flip control of the House.

• The Democratic Congressional Campaign Committee took aim at Rep. Nick Begich (R-Alaska) last week for voting against extending the enhanced ACA tax credits, saying premiums have risen 58% on average.
• It similarly targeted Colorado GOP Reps. Jeff Crank and Gabe Evans for their votes to cut Medicaid in last year's Republican tax-and-spending bill and refusal to extend ACA subsidies.
• Other ads in competitive House districts predict a "health care crisis" unleashed by the cuts will cost GOP incumbents their seats.

"Simply extending taxpayer subsidies deeper into the same broken system does not lower the actual cost of care," said a Begich spokesperson, adding the congressman wants to "address the underlying drivers of health care costs," paired with subsidies.

• "Citizenship verification and work requirements for able-bodied adults with no dependents or elderly parents in their care will only strengthen and sustain Medicaid for the long term," said a Crank spokesperson.

Between the lines: The ACA's Medicaid expansion could be an ongoing story through Election Day as more states implement work requirements ahead of a Jan. 1 deadline.

• The Center on Budget and Policy Priorities estimated that 20,000 people in Nebraska could lose coverage from the work requirements, or nearly 30% of the state's Medicaid expansion population.
• Advocates worry many people are in fact working but unaware of the new rules, or unable to verify that they are fulfilling the requirements.
• "It's really that red tape that's the problem, and it's what causes people to lose coverage," said Sarah Maresh, health care access program director at Nebraska Appleseed, a nonprofit involved in access to health care.

The other side: Nebraska Gov. Jim Pillen (R) said the requirements will "help Nebraskans achieve greater self-sufficiency through employment," when he announced his state would put the rules in effect more than half a year before the deadline.

• "Working not only provides purpose but helps people become active, productive members of their communities."

Reality check: Even with the dropoff in ACA marketplaces, signups are higher than they have been in many previous years.

• 23.1 million people signed up for 2026. That is down from the record high of 24.3 million in 2025 — though the number is expected to fall by several million as people drop out due to higher premiums.
• But enrollment will likely still be well above the numbers from before the enhanced subsidies were first passed in 2021, when there were around 12 million enrollees.
• "Once people get coverage, there's a certain momentum, and they try to keep it even if their premiums go up," Levitt said.

A spokesperson for the Centers for Medicare and Medicaid Services pointed to anti-fraud efforts as an explanation for lower sign-up numbers.

• 2026 signups were "only slightly below 2025 levels" and the drop could reflect "addressing unauthorized or fraudulent enrollments," as well as identifying individuals who may have been enrolled in multiple forms of coverage, the spokesperson said.
• Republicans argued during the debate over extending the enhanced subsidies that they were wasteful spending that benefited insurance companies.
• Health Secretary Robert F. Kennedy Jr., when pressed on the lapse during recent congressional testimony, noted that original ACA subsidies remain in place. He said 87% of ACA enrollees are paying less than $96 a month.