15 million fewer people would be covered by Medicaid in 2026 if the Senate health-care bill passes, according to a report put out by the nonpartisan Congressional Budget Office on Monday.

The bill sharply reduces federal funding for the Affordable Care Act’s Medicaid expansion. If states wanted to keep the expansion, they’d have to as much as quintuple their spending on those enrollees.


That leaves states with a difficult choice, according to Robin Rudowitz of the Kaiser Family Foundation. They can cut spending or raise taxes in other aspects of their budget, though “it’s a really big gap to fill.” They could limit who’s eligible for Medicaid — effectively undoing the expansion — or limit what benefits Medicaid enrollees get.

And maintaining that coverage will get more difficult over time, as the federal government gives states less money for the program. Aviva Aron-Dine, a senior fellow at the Center on Budget and Policy Priorities, said she expects states to be able to keep the expansion until 2022 or 2023. “As the costs mount, they’ll have to discontinue expansion. It’s just a question of timing,” Aron-Dine said.


 

Even among states that had broad Medicaid eligibility before the expansion, Rudowitz said, “I don’t think you can assume those states would maintain coverage.”

That’s especially true of a handful of primarily moderate and right-leaning states that have “trigger laws,” which would automatically or near-automatically end the Medicaid expansion as soon as federal funding dropped below a certain level.


 

But the expansion rollback and the 15 million enrollees losing coverage are just the beginning. The Senate bill caps Medicaid spending, meaning that each year as health-care costs get higher, states are going to have to make more cuts to their programs.

It’s unclear whether the Senate GOP’s bill will pass. Republicans will need almost all of their members to support it, but multiple senators have already expressed concern or outright opposition. And even if they find the votes, they'll still have to reconcile their measure with the House version and get President Trump to sign it. If the Senate measure becomes law, much of the Affordable Care Act's Medicaid expansion is likely to be reversed.