New analysis by the Congressional Budget Office (CBO) has ignited a wave of concern across the insurance sector, projecting that the Senate’s massive tax and spending bill could leave 11.8 million more Americans uninsured by 2034.
Dubbed the “One Big Beautiful Bill” by its sponsors, the legislation pairs $3.8 trillion in tax cuts with sweeping reductions in federal health spending. Insurance executives and public health experts are raising red flags over the projected coverage losses, which outpace the 10.9 million increase in the uninsured projected under the House-passed version.
Insurance Business spoke to Insurance Council of Texas, Executive Director Albert Betts to ask if the proposed legislation affect the broader insurance industry as carriers underwrite across multiple lines.
“As folks have auto accidents and need health care and treatment, there's often that when you have that accident, who's paying? Or even in workers' compensation. When an injury happens, who pays? ..... if it's work-related, it's the workers' compensation carrier.” said Betts
“Do we have to keep an eye out for any of that health care that individuals attempt to transfer over?” he said
At the heart of the Senate proposal are steep cuts to Medicaid — the largest single source of health insurance in the United States — and aggressive rollbacks of Affordable Care Act (ACA) subsidies. The CBO estimates the Senate version would slash Medicaid funding by $930 billion over a decade, compared to an $800 billion reduction in the House plan. Analysts say the magnitude of the cuts would ripple across low-income populations, Medicaid expansion states, and ACA marketplaces.
Among the most contentious elements is the imposition of work requirements for Medicaid eligibility. For the first time in the program’s 60-year history, the Senate proposal mandates that able-bodied adults aged 19 to 64 work at least 80 hours per month to maintain coverage. Unlike the House version, which exempts parents of dependent children, the Senate bill applies this requirement to parents of children aged 14 and older — a move advocates warn will disproportionately affect single-parent households.
Additionally, roughly 1.4 million individuals without “satisfactory immigration status” would lose access to coverage under the Senate plan, underscoring its broad and punitive scope.
Insurance leaders worry these changes would fuel market instability. As millions fall off the rolls, risk pools could shrink and skew older and sicker, driving up premiums. The withdrawal of ACA subsidies threatens to further destabilize exchanges, as lower-income enrollees find themselves priced out of coverage.
Beyond the insurance implications, the CBO projects the Senate bill would add $3.3 trillion to the federal deficit over the next decade — nearly $900 billion more than the House counterpart. This raises significant questions about the bill’s compliance with the Senate’s Byrd Rule, which prohibits legislation from increasing the deficit beyond a 10-year window.
These fiscal dynamics may pose a challenge for Republican lawmakers aiming to pass the bill through reconciliation, a process that requires strict budgetary alignment. Yet even if the bill clears procedural hurdles, its consequences for public health coverage could be profound.
For insurers and healthcare providers, the stakes are immense. The rollback of ACA supports threatens enrollment and revenue in individual markets. Medicaid managed care organizations face a dramatic restructuring of their business models, with eligibility redeterminations and reduced federal matching funds likely to erode margins. Hospitals, particularly safety-net providers, could see a surge in uncompensated care.
As the Senate nears a final vote, the insurance industry continues to scrutinize the proposal’s implications. With coverage gaps poised to widen and financial protections eroding, stakeholders across the healthcare continuum are bracing for a policy landscape that could transform the structure of public insurance for decades to come.
