As the Trump administration takes aim at fraud, waste and abuse in the Affordable Care Act (ACA) market, Republicans in Congress are touting new data from the Congressional Budget Office (CBO) as evidence backing the effort.
Legislators asked the CBO to dig further into the potential coverage impacts of the One Big Beautiful Bill Act, a massive and far-reaching reconciliation package that includes significant overhauls in healthcare. The analysis (PDF) found that 2.3 million individuals received premium tax credits improperly by misstating their income.
That grew from 1.3 million people who did the same in 2023, according to the CBO.
It also estimates that if income verification requirements, which were established as part of a recently finalized regulation, had been in place previously, about 500,000 fewer people would have received enhanced premium subsidies on the exchanges.
The CBO also said the bill could lead to a 0.6% decrease in premiums on the exchanges in 2034.
The OBBBA also restricts immigrants’ access to ACA marketplace coverage, and the CBO estimates that this will lead to about 900,000 people losing coverage by 2034. Policy changes to prevent immigrants from receiving enhanced premium tax credits, or EPTCs, would lead to a further 300,000 coverage losses, the report shows.
The chairmen of three key House committees—Energy and Commerce, Ways and Means and Budget—requested the CBO examine these implications. E&C Chair Brett Gutherie, R-Ky.; Ways and Means Chair Jason Smith, R-Mo.; and Budget Chair Jodey Arrington, R-Texas, released a joint statement blaming Democrats for the trends.
“CBO found Democrats’ policies to be responsible for massive waste, fraud, and abuse in federal health programs, even forcing taxpayers to pay for the health care of illegal immigrants, including some of the worst criminal offenders,” they said. “Thanks to the One, Big, Beautiful Bill, Republicans are protecting taxpayers and delivering pro-growth tax cuts for Americans.”
The CBO report did not make mention of criminal behavior on the part of immigrants who may have accessed ACA coverage or the enhanced subsidies.
The OBBBA did not extend the premium tax credits, which are set to the expire at the end of this year. And, given that a GOP-controlled Congress appears unlikely to choose an extension, insurers have submitted significant increases for premiums in 2026, anticipating the end of those credits as a key factor.
Insurance and provider groups alike have pushed for the tax credits to be extended and have also pushed back on characterizations that suggest massive, widespread fraud on the exchanges. The American Hospital Association (AHA) released a response to criticisms of the market.
Much of the Centers for Medicare & Medicaid Services’ push around Medicare fraud comes from analyses at the Paragon Health Institute, a conservative think tank. The AHA leaders, however, argued in an op-ed that their baseline for determining fraudulent behavior is flawed.
Paragon has put an emphasis on people who enrolled in ACA plans but have no claims in a given year, suggesting that means they have been enrolled unknowingly or otherwise inappropriately. The AHA said, though, that this is not an uncommon trend and is often to key to managing risk pools in insurance.
“Risk pooling depends on a mix of healthy and sick enrollees where healthier individuals with few to no claims help offset the costs of sicker enrollees. Without healthy enrollees, premiums would skyrocket, and the market could collapse,” according to the post.
In addition, the AHA notes that the data include people who leave their coverage midyear, or who switch plans, which can lead to them being represented multiple times. The organization also argues that solutions put forth by Paragon, including a greater reliance on short-term limited duration plans, would have a negative impact on patients.
“As Congress weighs the extension of the EPTCs—a critical tool in supporting access to affordable care and coverage—it is imperative that the Marketplace debate is grounded in fact, not fiction,” the post said.