By John C. Goodman, Heartland Institute
The media are clamoring over the Congressional Budget Office’s estimate that 16 million people will lose health insurance by 2034 because of the Trump administration’s policies—10.9 million due to the One Big Beautiful Bill Act alone.
Most of the news coverage misses three important details. While it’s true that many people will lose insurance, that doesn’t mean a significant loss of health care.
Not a Crisis
First, most of those who will lose coverage are almost certain to be healthy and not in need of medical care. The bulk of the loss from the One Big Beautiful Bill (7.8 million) will be a reduction in Medicaid enrollment. Nearly five million of these are able-bodied people without dependents, who the CBO predicts will balk at the requirement to work 20 hours a week (or go to school or engage in community service).
The remaining losses are mainly due to paperwork: more frequent eligibility verification, the need for proof of citizenship or legal immigration, and changes in processing applications and renewals.
Second, if people who lose coverage later get seriously sick, they can easily re-enroll and get Medicaid to pay their bills retroactively. Currently, there’s a three-month look-back period for coverage. Beginning in 2027, retrospective payment will be limited to one month for Medicaid expansion enrollees and two months for traditional enrollees. This should be more than enough time for a patient to get the coverage he needs. If a hospital or nursing home can’t manage to enroll a patient in 30 days, it needs new management.
Not Worth the Hassle
It’s a similar story with the other largest portion of insurance loss. The CBO estimates 7.3 million people on the Obamacare exchanges will soon be without coverage for two reasons: a Biden-era expansion of enhanced tax credits will expire at the end of the year, and the One Big Beautiful Bill increases administrative barriers to enrollment.
Those who end up without insurance because of this will almost all be healthy, because they are the most likely to give up in the face of more paperwork. One of the reasons health insurers are announcing an 18 percent increase in premiums in next year’s exchanges is that they expect healthy people to leave, making the remaining pool sicker and more costly.
If someone who drops out of Obamacare gets sick, it isn’t difficult to get back on. Theoretically, he’s supposed to wait until the next open enrollment period (November 1 through January 15). But he can qualify for immediate enrollment if there is a “qualifying event” such as getting married, having a baby, or moving to a new ZIP Code. Native Americans and Alaskan Natives have access to continuous open enrollment.
Third, having health insurance isn’t the same as having health care. Although Obamacare (including the Medicaid expansion) has helped cut the number of uninsured people in the United States nearly in half, all that spending has resulted in very little benefit, including for enrollees.
Twenty Cents on the Dollar
Medicaid enrollees actually place a low value on enrollment. Low-income adults value their Medicaid coverage at about 20 to 50 cents on the dollar of what their plans cost the taxpayers.
Medicaid also doesn’t seem to make much difference to enrollees’ health. The most rigorous study of the matter was the Oregon Health Insurance Experiment, a one-of-a-kind randomized controlled trial. Researchers selected Medicaid enrollees by lottery.
After two years, researchers compared the medical conditions of those on Medicaid and those not on it. Those who had enrolled had less financial stress and were less likely to be depressed, but there was no significant improvement in their physical health.
‘Implicit Insurance’
As one of the Oregon investigators, MIT economist Amy Finkelstein, explained in a recent interview, people without health insurance still get about 80 percent of the health care that Medicaid enrollees do. When they’re confronted with high medical bills, they usually pay only a small portion of them.
Sometimes this means taking on debt, but as Ms. Finkelstein said in MIT Newson December 15, 2018, “the nominally uninsured have a fair amount of implicit insurance.” This can include help from nonprofit hospitals or government-funded health clinics.
This makes Medicaid of little marginal value. Among the lottery winners who were offered enrollment in the Oregon study, more than half turned it down.
Fake Access
Obamacare likewise has done little to improve access to health care. A study in the American Journal of Public Health found that after the introduction of Obamacare, there was a small increase in the number of low-income patients who had at least one doctor’s office visit.
That, however, was offset by “small, nonsignificant reductions” among the rest of the population. There was no change for the population as a whole.
The United States has spent almost $200 billion a year on Obamacare subsidies. If the One Big Beautiful Bill can reduce some of this waste, it will cause little harm while saving taxpayers a lot of money.
John C. Goodman, Ph.D., (johngoodman@goodmaninstitute.org) is co-publisher of Health Care News and president and founder of the Goodman Institute for Public Policy Research. A version of this article was published in The Wall Street Journal on August 25, 2025. Reprinted with permission.
John C. Goodman is president of the Goodman Institute for Public Policy Research.
