The Medicaid and marketplace proposals from the Heritage Foundation’s Project 2025^[1] blueprint, the Republican Study Committee’s (RSC) fiscal year 2025 budget,^[2] and the Republican House Budget Committee’s (HBC) fiscal year 2025 budget resolution^[3] would undermine Affordable Care Act (ACA) coverage protections, make health coverage more costly and less comprehensive, shift more costs to states, and increase the number of uninsured people in the U.S. These proposals would result in a future in which millions more people go without coverage, pay higher premiums if they have pre-existing conditions, or end up with skimpy health plans that don’t cover benefits they need.^[4]

This paper focuses on the three plans’ proposed changes to eligibility requirements, consumer protections, financing, and coverage generosity for Medicaid, ACA marketplace insurance, and other health insurance. These and other conservative proposals set forth a vision that contrasts dramatically with recent coverage and affordability gains. This paper does not address these plans’ full range of health proposals, which also include scaling back rights and revoking access to health and economic supports for specific groups, including women, people of color, people with low incomes, people who are immigrants, and LGBTQ+ people. In particular, Project 2025’s health care agenda predominantly focuses on banning abortion and limiting access to contraception, rather than addressing high health care costs or reducing uninsurance.These proposals would result in a future in which millions more people go without coverage, pay higher premiums if they have pre-existing conditions, or end up with skimpy health plans that don’t cover benefits they need.

While the proposals do not present themselves as repealing the ACA, the results would be much the same: higher costs for health coverage, loss of protections for people with pre-existing conditions, and an increase in the number of people without insurance. The plans call for undermining the ACA’s Medicaid expansion and making deep additional cuts in Medicaid, which would take away health coverage, raise the cost of health care, or reduce access to needed health services for millions of people. Children, parents, and people with disabilities could face higher costs and lower access to health coverage, and millions of low-income adults could be left with no options for affordable coverage. (See Figure 1.)

The RSC proposal would slash $4.5 trillion in federal investment in Medicaid, Children’s Health Insurance Program (CHIP), and marketplace coverage.^[5] The similarly harsh HBC budget resolution includes $2.2 trillion in cuts to health coverage, and the report accompanying the resolution suggests that all of the cuts would come from Medicaid; if true, the cuts would amount to 30 percent over ten years, on average, and 40 percent in 2034.^[6] The size of the cuts under Project 2025 is less clear but would also be extremely large.

The U.S. has made significant progress toward universal health coverage since the ACA’s enactment.^[7] Uninsured rates have also fallen significantly across racial and ethnic groups since the ACA’s major coverage provisions took effect.^[8] The proposals described here would roll back that progress via huge cuts to Medicaid and federal premium tax credits and by weakening protections for people with pre-existing conditions, taking the nation back to the pre-ACA era^[9] — or worse —and disrupting and making health care unaffordable for millions of people.