What are the Congressional Budget Office estimates of coverage losses and fiscal impacts from the 2025 reconciliation law on immigrant populations?
Executive summary
The Congressional Budget Office (CBO) estimates that the 2025 reconciliation law will raise the national uninsured count by about 10 million people by 2034 relative to its January 2025 baseline, with most of those coverage losses driven by Medicaid/CHIP and Marketplace changes that disproportionately affect lawfully present immigrants [1] [2]. On the fiscal side, CBO scores show hundreds of billions in federal savings from reductions in Medicaid and Marketplace subsidies over ten years, while analysts and immigrant advocates warn those savings reflect concentrated harms to immigrant communities and state programs [2] [1] [3].
1. How many people — and which immigrants — lose coverage under CBO’s estimates
CBO’s net tally for the enacted reconciliation package is an increase of roughly 10 million uninsured in 2034, and CBO attributes about three‑quarters of those coverage losses to the law’s Medicaid and CHIP cuts, which alone increase the uninsured by about 7.5 million in 2034 after accounting for interactions [1]. Separately, CBO estimated that provisions restricting subsidized Marketplace eligibility for many lawfully present immigrants will increase the uninsured by about 900,000, and removal of a special Marketplace rule for very low‑income lawfully present immigrants will add roughly 300,000 uninsured [4]. CBO also isolates a provision that restricts Medicare eligibility for some lawfully present immigrants as adding roughly 100,000 uninsured in 2034 [1] [3].
2. The fiscal math CBO reports: hundreds of billions in federal savings, large state shifts
CBO and Joint Committee on Taxation scoring of the bill show major federal spending reductions: hundreds of billions in decreased Medicaid spending and reduced Marketplace financial assistance — figures reported include about $806 billion less federal Medicaid spending over ten years and about $301 billion less for Marketplace subsidies in some CBO summaries of earlier drafts [2], and broader reporting places total Medicaid/Marketplace cuts near $990–$1.1 trillion across the decade depending on which line items are grouped [1] [3]. Some narrower provisions are scored as more modest savings — for example, CBO estimates a specific emergency Medicaid match change would reduce federal Medicaid spending by $28 billion over ten years and is not expected to affect coverage [5].
3. Where immigrants are concentrated in CBO’s breakdown — and what CBO didn’t fully parse
CBO’s section‑level estimates explicitly target sections 71301–71305 for immigrant‑related eligibility changes and allocate coverage and budget effects across Medicaid, the ACA Marketplaces and Medicare [6]. Advocacy groups — Georgetown CCF, KFF, NILC and others — have used CBO’s scores to estimate that roughly 1.2–1.4 million specific immigrants could lose state‑funded or other coverage in modeled scenarios and that nearly 1.4 million additional people could lose coverage under some earlier penalty proposals targeting states, though that penalty language was not part of the final enacted package and thus is treated differently in CBO’s enacted‑law estimates [7] [8] [3] [9]. CBO itself notes limits on what it breaks out — some emergency care and state‑funded program spending flows were not separately itemized for particular immigrant subgroups in CBO’s public tables [10] [6].
4. Competing framings and hidden agendas in the coverage and fiscal narrative
Policy shops and advocates emphasize different parts of CBO’s score: progressive groups underscore the human coverage toll and say the savings are achieved by cutting health access for lawfully present immigrants (CCF, NILC cite CBO figures) while fiscal conservatives highlight the headline deficit and spending reductions [1] [3]. Some earlier media and fact‑checking pieces flagged that estimates for state behavior — for example, whether states would stop state‑funded immigrant programs when federal matches changed — hinge on assumptions, so “1.4 million” coverage‑loss figures tied to a proposed state penalty were tied to scenarios and not a literal enacted outcome [7] [9]. CBO’s own public materials and KFF analysis stress that combining the law’s effects with the scheduled expiration of enhanced premium tax credits would push projected uninsured increases even higher, above 14 million in some combined‑scenario counts [11] [12].
5. What remains uncertain and what CBO cannot tell the public
CBO provides point estimates and scenario allocations but does not and cannot precisely map every subpopulation’s real‑world response, state policy reactions, or short‑term enrollment churn; advocacy groups warn those modeling choices may understate localized harms and the interaction with state‑level programs [6] [10] [13]. Where CBO did not break out certain emergency Medicaid flows by immigration status or disentangle all state‑only programs from federal effects, outside analysts filled gaps with modeling assumptions that produce a range of estimates — meaning the headline numbers are authoritative for budget scoring but carry modeling caveats in translating to lived impacts for immigrant communities [10] [13].