In June 2025, LDI Executive Director Rachel M. Werner, MD, PhD, LDI Director of Research Norma Coe, PhD, and LDI Senior Fellow Eric T. Roberts, PhD collaborated with researchers at Yale School of Public Health in response to a request for technical assistance from the Senate Finance Committee and the Senate Committee on Health, Education, Labor & and Pensions (HELP) regarding the potential mortality effects of several provisions in the House-passed reconciliation bill.

The researchers project that implementation of the retractions outlined in the reconciliation bill would result in more than 42,500 deaths annually.

Additionally, the proposed bill fails to extend the Enhanced ACA Premium Tax Credits. Including that impact, the researchers project that these changes will result in over 51,000 preventable deaths.

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June 3, 2025

Dear Ranking Members Wyden and Sanders:

Thank you for your inquiry about the potential mortality impacts that would result from several provisions of the House-passed budget reconciliation bill.

In response, we estimated the number of lives that could be lost based on three effects of the reconciliation bill: (1) an estimated 7.7 million people losing Medicaid or Affordable Care Act Marketplace coverage in 2034 (as estimated by the Congressional Budget Office’s May 11, 2025 communication), (2) 1.38 million dual-eligible beneficiaries losing Medicaid coverage from disenrollment in the Medicare Savings Programs (as estimated by the CBO in their May 7, 2025 communication), and (3) immediately rescinding the CMS rule setting a national floor for minimum nursing home staffing levels.

We project that implementation of the retractions outlined in the reconciliation bill would result in more than 42,500 deaths annually. This includes:

1. 11,300 deaths from the loss of Medicaid or Affordable Care Act Marketplace coverage due to 7.7 million people losing coverage¹
2. 18,200 deaths due to the loss of Medicaid coverage among 1.38 million low-income Medicare beneficiaries, causing loss of access to low-income prescription drug subsidies²
3. 13,000 deaths among Medicaid enrollees in nursing homes due to the rollback of CMS’ 2024 nursing home minimum staffing rule.³

To calculate these, we used peer-reviewed estimates of the relationship between mortality and (1) loss of Medicaid coverage for adults aged 19-64; (2) loss of medication coverage for low-income Medicare beneficiaries through the low-income subsidy;⁴ and (3) rescinding minimum nursing home staffing levels for total nurse staffing hours per resident day. We applied these estimates to the number of people at risk from these provisions. Because each of these three provisions affect distinct groups (1) individuals who lose all Medicaid coverage; (2) community-dwelling individuals who lose Medicaid coverage but retain Medicare coverage; and (3) individuals residing in nursing homes with lower staffing levels, we sum these projections together to a total number of 42,500 deaths in one year.

In addition, the proposed bill fails to extend the Enhanced ACA Premium Tax Credits. Expiration of this policy is expected to lead to the loss of insurance for another 5 million people, bringing the total number of uninsured individuals to 13.7 million. We calculate that this retraction will cause an additional 8,811 deaths.

Altogether, we project that these changes will result in over 51,000 preventable deaths.

Further details on these calculations can be found in the notes and supplemental documents linked below. We would be happy to discuss these findings or provide additional information that might be helpful.

Thank you for the opportunity to use this evidence to inform your work.

Sincerely,

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1. See https://www.medrxiv.org/content/10.1101/2025.05.19.25327564v1.full.pdf+html; and https://www.pnas.org/doi/10.1073/pnas.2321494121. We note that while the CBO estimates 7.7 million insurance losses from all Medicaid provisions, a prior analysis focusing solely on work requirements, projects 5.6 to 6.3
   million individuals losing coverage (https://www.urban.org/research/publication/expanding-federal-workrequirements-medicaid-expansion-coverage-age-64-would). Our calculations, based on these losses, indicate that the work requirement alone could lead to over 10,000 excess deaths annually (https://www.medrxiv.org/content/10.1101/2025.02.28.25322887v2.full.pdf+html), making our estimate of 11,308 deaths conservative.
2. https://www.nejm.org/doi/abs/10.1056/NEJMsa2414435; see https://ldi.upenn.edu/our-work/research-updates/research-memo-loss-of-subsidized-drug-coverage-and-mortality-following-medicaid-disenrollment-translating-our-findings-and-implications-for-medicaid-policy/ for additional detail.
3. See https://ldi.upenn.edu/our-work/research-updates/comment-the-impact-of-repealing-the-centers-for-medicareand-medicaid-services-minimum-staffing-rule-on-patient-outcomes/ for additional detail.
4. The low-income subsidy is automatically provided to Medicare beneficiaries who also have Medicaid. Consequently, loss of Medicaid coverage often leads to loss of the low-income subsidy.

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