300,000 Pennsylvania residents could lose Medicaid under ‘big, beautiful bill’

Some 3 million Pennsylvania residents are covered by Medicaid, the publicly funded health program marked for $900 billion in cuts over the next decade with congressional Republicans approving on Thursday President Donald Trump’s “big, beautiful bill.”

About one in four of them — roughly 750,000 people — are eligible for Medicaid under rules now targeted for cost-reduction measures in the sweeping domestic spending and tax policy package that Trump is expected to sign into law.

In Philadelphia alone, about 183,000 people have Medicaid coverage through rules enacted under the 2010 Affordable Care Act that expanded access to the federal- and state-funded health program for low-income individuals, children, seniors, and people with disabilities, according to Pennsylvania Department of Human Services estimates.

The so-called Medicaid expansion group would face new reporting and cost-sharing requirements under legislation.

These Medicaid restrictions could lead to some 300,000 Pennsylvania residents losing coverage, estimates released by Gov. Josh Shapiro’s office show.

But the Medicaid provisions in the Republicans’ bill won’t begin to take effect until the end of 2026, after the midterm elections. That pushes back the timeline for states to make difficult decisions about how to respond to the legislation.

» READ MORE: The ‘big, beautiful bill’ is poised to cut Medicaid. Here’s what’s at stake for five Philly-area families.

Pennsylvania expanded Medicaid eligibility in 2015 to people whose income falls within 138% of the federal poverty rate for their household size. For one person, the maximum income is $21,597. For a family of three, it’s $36,777.

Income thresholds are higher for pregnant women and children under a year old.

Other eligibility requirements include having a Social Security number, owning government-issued identification, and being a Pennsylvania resident.

Philadelphia County alone accounted for 23% of Pennsylvania’s total Medicaid enrollment, with about 670,000 residents who rely on the program.

Notably, Cameron County, Pennsylvania’s second-least populous county, is on this list, highlighting how smaller counties can still have high Medicaid participation.

Senior Pennsylvania residents, aged 65 and over, also qualify for Medicaid based on income and asset thresholds. The monthly income limit is set at $989 for seniors.

Medicaid expansion was a key provision in former President Barack Obama’s 2010 Affordable Care Act, which aimed to expand access to health insurance.

Previously, it was extremely difficult for single adults to get coverage through Medicaid.

The Medicaid expansion group includes working adults who do not earn enough to afford health insurance on their own or aren’t eligible for it through an employer; adults who retired early and don’t yet qualify for Medicare (the federally funded coverage for people 65 and over); and people with disabilities who haven’t been approved for federal disability benefits.

Many of these people, including seasonal and contract workers, such as nurses and daycare teachers, gained coverage for the first time through Medicaid expansion.

Pennsylvania’s Medicaid expansion enrollees are concentrated in the populous southern corners of the state, anchored by high enrollment in Philadelphia and Allegheny Counties.

Nearly one in four of Pennsylvania’s expansion enrollees lives in Philadelphia, which has a Medicaid expansion population 2.9 times bigger than Allegheny’s.

Three of Philadelphia’s collar counties — Delaware, Montgomery, and Bucks — also have high expansion participation with 15,000 or more residents covered through the ACA’s Medicaid expansion.

The bill passed by Congress, with all Democrats opposed, includes $896 billion in cuts to Medicaid.

Five provisions account for 87% of the savings, according to KFF, a nonprofit health education organization.

Some of the bill’s hardest-hitting cuts — work requirements and twice-yearly renewals — are directed at the Medicaid expansion group.

New cost-sharing requirements specifically were created for people who qualify under expansion rules. States would be required to charge them a copay of up to $35.

Republicans say the goal of the copays and work requirements are to ensure that people who receive public assistance are invested in their own healthcare and actively contributing to society.

Patient advocates argue that even small copays could deter people with limited income from seeking needed healthcare.

The bill would require people who qualify for Medicaid under expansion rules to work at least 80 hours a month and submit proof of their hours to the state on a monthly basis.

The Congressional Budget Office estimated that this rule alone would result in 5.2 million people losing Medicaid, and the vast majority of them — about 4.8 million — becoming uninsured by 2034. That’s because few would be able to secure employer-based coverage, and none of them would be eligible for tax credits in the ACA marketplaces, like Pennie.

Locally, Pennsylvania Health Action Network estimates some 998,000 adults would be required to verify their work or their eligibility for an exemption on a monthly basis.

About 240,000 people would lose coverage because of work requirements — even though a majority of them have jobs, according to an analysis by PHAN, a nonprofit organization that helps people enroll in coverage.

About 80% of adults who would be subject to work requirements are already working at least 80 hours or would qualify for an exemption, according to KFF.

This suggests people at risk of losing coverage will largely be working adults who are unable to keep up with the arduous process of proving and reporting their hours to a state agency every month.

“The overwhelming number of folks who will lose coverage lose it because they can’t navigate this new system,” said Patrick Keenan, director of policy & partnerships for PHAN.

Pennsylvania lawmakers have limited time to figure out how they will account for losing tens of thousands of Medicaid dollars every year.

The legislation calls for work requirements and six-month eligibility checks to take effect at the end of 2026.

In addition to funding losses, Pennsylvania officials say they will need to spend at least $25 million on new technology and employees to enforce the new requirements.

Shapiro, a Democrat, has said Pennsylvania does not have the money to cover the anticipated loss, and that lawmakers will likely be forced to tighten eligibility and reimbursement rates.

“There’s no way to protect seniors and people with disabilities when you’re cutting millions,” Keenan said. “Even if you came up with all the solutions, you’re just not going to get that kind of money.”