To hear the White House tell it, the tax reform bill that passed the House and the Senate this week was centered on providing relief to the middle class. Within the constraints of its tax-focused components alone, that argument was a stretch: The bill was heavily weighted to the wealthiest Americans and to businesses, with advocates arguing that this would eventually, indirectly benefit middle-class people as new jobs were created (ignoring that unemployment is already at the lowest point in decades).

But for a variety of reasons, including the need to show big cuts in spending to ensure that only 50 votes were needed for passage in the Senate, the “tax reform” package included several other elements that the White House began talking about only after it passed. At an event on the South Lawn of the White House after the House voted its approval of the bill, President Trump noted one of those additional provisions.

“I hate to say this,” Trump said, “but we essentially repealed Obamacare, because we got rid of the individual mandate, which was terrible. And that was a primary source of funding of Obamacare.” He then went on to celebrate another issue that had been tacked on to the bill: opening the Arctic National Wildlife Refuge to oil drilling.

That repeal of the individual mandate, though, is important. It is not a repeal of the Affordable Care Act; analysts and insurers expect premiums to rise but for Obamacare to continue moving forward after the repeal. What it does do, though, is ensure that a significant number of Americans will lose or drop insurance coverage over the next decade.

This is the second time in a few months that Congress has taken an action that would lead to a reduction in the number of Americans with insurance. Though, really, the other issue was an inaction — Congress failing to renew the Children’s Health Insurance Program, or CHIP. There have been repeated assurances that CHIP will be renewed, but it expired almost three months ago without any congressional action to date.

The combination of those two changes to federal health-care law will mean millions — and maybe tens of millions — fewer Americans having health-care coverage. Here’s how the numbers break down.

Repealing the individual mandate

The individual mandate in Obamacare was indeed meant to help make the economics work. Since the law mandated that insurers affordably cover everyone, including those with preexisting conditions — who, therefore, would probably cost insurers more money — the law made it so that everyone either had to have insurance coverage or pay a fine. That’s the mandate, and it was meant not only to ensure that healthy, often-younger Americans had coverage in the event of an emergency but also to have a pool of people paying into the system who were less likely to take money out in the form of expensive care.

When Congress was debating whether to repeal the mandate earlier this year, the nonpartisan Congressional Budget Office compiled an analysis of how repealing the mandate would affect the number of people with coverage. The math is complicated, involving, among other things, a number of people who would simply drop coverage now that there was no penalty for doing so.

The upshot is that about 13 million more people would lack coverage by 2025 — or, since the repeal passed, probably will lack coverage.


How will the effects be distributed? A number of people will drop out of the Obamacare health-care marketplaces — about 5 million by 2021. As you might expect, marketplace enrollment is larger in places with larger populations.


The progressive Center for American Progress looked at the distribution of the likely declines by state, factoring in the other components of the expected drop in the number of insured. In its estimation, a number of northeastern states will see bigger drops in the number of insured than other places, with Texas, Florida and California — high-population states — also seeing big decreases.

(These figures are for people under 65; those over are generally eligible for Medicare.)


Again, this is based on a CBO estimate, so the numbers may end up larger or smaller. But the estimate is based on the actual policy step that will be signed into law by Trump at some point soon — meaning that we can anticipate millions of people losing coverage as a result.

Allowing CHIP to expire

Then there’s CHIP. Last year, just shy of 9 million children were enrolled in the program nationally, excluding those children enrolled in Medicaid. Again, and predictably, more populous states saw higher enrollment.


As funding runs out for these states, they will begin to scale back that coverage. On Wednesday, the state of Connecticut announced that it was ending its coverage program for children unless CHIP was renewed shortly. The state expects to run out of money for the program by the end of next month.

It’s not alone. Analysis from the Georgetown University Health Policy Institute found that, without renewal of CHIP, nearly 3 million children could lose coverage by the end of February.


That loss of coverage is preventable, if Congress were to renew the program shortly. However, the funding lapsed at the end of September; Congress hasn’t acted in the intervening 80-plus days. On Thursday morning, the House introduced a short-term extension of CHIP funding through March as part of a budget resolution. It has not yet been voted on.

Earlier this week, House Speaker Paul D. Ryan was interviewed by ABC News and predicted that, to address the budget deficit — a deficit that could be as much as 10 percent higher than it otherwise would be thanks to the tax-reform bill — the Republican Congress would look at cutting spending on social safety net programs next year. Such a move could mean less funding for Medicare, among other things, which could mean further reductions in the number of people covered under that program.

The full extent of the reduction in the number of people with health insurance during the Trump presidency, in other words, is still to be determined. But there will almost certainly be a significant reduction.