A repeal of the Affordable Care Act (ACA) is now in motion in Congress and has the potential to impact every state’s Medicaid program and individual health insurance market. The ACA increased health insurance coverage by expanding Medicaid, offering tax credits to low- and middle-income Marketplace enrollees, and reforming insurance market rules around coverage for people with pre-existing conditions. The Republican replacement plan passed by the House of Representatives, the American Health Care Act, would maintain many of these market rules but give states the option to waive certain rules, including the requirement that insurers not charge people with pre-existing conditions higher premiums.  It also would restructure the premium tax credits to be mostly flat (based on age), meaning that low-income individual market enrollees would receive a smaller tax credit and higher-income enrollees would receive a larger tax credit. In addition, the AHCA would roll back the ACA’s Medicaid expansion by phasing out enhanced federal funding for this coverage and would significantly reduce other federal Medicaid funding over time by limiting federal Medicaid financing under a per capita cap or, at state option, a block grant for some enrollees.

The map and tables below highlight the increases in health insurance coverage through Medicaid and the Marketplaces as well as the increased federal funding that resulted from the implementation of the ACA. Table 1 provides data on the number of people whose coverage could be affected by the AHCA as well as the gains in coverage in each state under the ACA.

 Table 1: Medicaid & Marketplace Enrollment

Table 2 provides data on federal Medicaid spending in states from January to March 2016 (the most recent data available) as well as the value of tax credits received by Marketplace enrollees. Under current Medicaid rules, states also pay a share of Medicaid costs, with the federal government matching states’ spending on an open-ended basis. The federal share of Medicaid is based on a formula that accounts for state income and is designed so that the federal government pays a larger share of program costs in poorer states. In 2017, the federal share (FMAP) ranged from 50% to 74%. States receive a higher FMAP of 95% in 2017 for the Medicaid expansion population, which phases down to 90% in 2020.  

Table 2: Medicaid & Marketplace Financing