ESTIMATE: At Least 48 Million Could Become Uninsured Under Paul Ryan’s Budget

Since Rep. Paul Ryan’s (R-WI) new budget eliminates $1.5 trillion from the Affordable Care Act, cuts $770 billion from Medicaid and reduces Medicare spending by $200 billion, Ezra Klein points out that “it would be very interesting to see an estimate of the uninsured population under Ryan’s budget.” The Congressional Budget Office (CBO) analysis of Ryan’s plan does not provide those numbers, but a rough back-of-the-envelope estimate suggests that at least 48 million Americans could lose their health insurance:

Here is how:

— 33 MILION FROM HEALTH REFORM: The budget repeals the Affordable Care Act’s requirement to purchase health insurance coverage, the provision of subsidies for lower-income Americans, and the expansion of the Medicaid program. In other words, it completely defunds the law’s investment in reducing the number of uninsured. As a recent CBO estimate found, compared with prior law, “the ACA is now estimated by CBO and JCT to reduce the number of nonelderly people without health insurance coverage by 30 million to 33 million in 2016 and subsequent years.”

— 15 MILLION FROM MEDICAID CUTS: The budget would eliminate the existing matching-grant financing structure of Medicaid and would instead give each state a pre-determined block grant that does not keep up with actual health care spending. This would shift some of the burden of Medicaid’s growing costs to the states, forcing them to — in the words of the CBO — make cutbacks that “involve reduced eligibility for Medicaid and CHIP, coverage of fewer services, lower payments to providers, or increased cost sharing by beneficiaries—all of which would reduce access to care.” The block grants would reduce federal Medicaid spending by $810 billion over 10 years, decreasing federal Medicaid spending by more than 35 percent over the decade. As a result, economists estimate that states could reduce enrollment by more than 14 million people, or almost 20 percent—even if they are were able to slow the growth in health care costs substantially.

— 1 MILLION FROM MEDICARE AGE INCREASE: The House budget would raise Medicare’s age of eligibility from 65 to 67 by 2034. CBO estimates that while such proposals would reduce Medicare spending by about $150 billion over 10 years, the change would affect roughly 5.4 million seniors. Of this group, about 2.7 million seniors would pick up health insurance offered by employers. Some of the remaining seniors would obtain coverage through Medicaid, qualify for Medicare because they are disabled, or purchase private health insurance in the direct purchase market. But since the House budget would also cut Medicaid and repeal reforms in the Affordable Care Act that would make the direct-purchase market accessible and affordable, many more seniors would become uninsured.