The primary mechanism that Democrats say will murder the masses is the law’s reforms to Medicaid, citing a Congressional Budget Office estimate that 11.8 million people who would otherwise be insured will be booted off Medicaid by 2034. This, of course, ignores the fact that every welfare program, even those without automatic spending cuts, such as the 24% across-the-board benefit cut Social Security will face in the next seven to eight years, involves trade-offs.

For starters, this 11.8 million figure isn’t quite what it seems.

More than 2 million of those supposedly booted from Medicaid were already ineligible for it anyway and were discerned as such through heightened verification. Another 1.4 million are illegal immigrants who will be barred from coverage as a part of the law’s penalty for states that siphon off their local Medicaid funds to illegal immigrants. Nearly 5 million would be able-bodied adults without any dependents who fail to work, volunteer, or go to some sort of school or job training for 20 hours per week.

Subtract half a million from this number for people who fall into two or more of these categories. The CBO says that of these 7.8 million, 1.6 million “would have access to, but would not take up, other forms of subsidized coverage, such as premium tax credits for insurance purchased through the marketplaces established by the Affordable Care Act or employment-based coverage; that number also includes people who would remain eligible for Medicaid but would not enroll.”

On top of this nominal 7.8 million, 1.3 million more people would not have health insurance in nine years because the law slightly reduces the amount of money the federal government contributes to plans purchased on Obamacare exchanges, but only for those above the federal poverty line. Another 2.3 million would theoretically lose coverage because the law revokes some premium tax credits for noncitizens, including illegal immigrants.

Exclude those 1.6 million who choose not to access other forms of subsidized healthcare, and you have some 9 million uninsured. Subtract noncitizens and those who weren’t eligible to start with, and the number falls closer to 3 million able-bodied adults who are either not actually impoverished or not working the bare minimum for an able-bodied, childless adult.

But a better way to think of whether these are actually healthcare cuts in absolute terms is through the lens of opportunity cost.

Consider a 2019 JAMA Cardiology study comparing the patient outcomes of those hospitalized for acute myocardial infarction in states that didn’t expand Medicaid after Obamacare versus those that did. While expansion states saw a reduction in the share of AMI patients who were uninsured, “quality of care and outcomes did not improve among low-income adults in expansion compared with non-expansion states.”

A 2017 study from the New England Journal of Medicine found that expansion states saw appointment wait times worsen by nearly 3%. A 2021 study published by Health Services Research determined that Medicaid expansion exacerbated hospital wait times to the point that the percentage of patients who left ERs without being seen at all rose 15%.

Without technological innovations that improve medical productivity or an increase in the supply of healthcare professionals maturing into the industry, every policy proposal for taxpayer-funded healthcare is a trade-off. Sen. Bernie Sanders (I-VT) may warn that the new law will kill 50,000 people every year. But robbing Medicaid’s originally intended beneficiaries — severely disabled people, pregnant women, and impoverished elderly people — to pay for illegal immigrants and childless adults choosing not to work will also cost lives in the end.

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None of this is to mention Medicaid’s abysmal performance relative to private health insurance, which was largely crowded out by the Obamacare expansion to the point that nearly half the country is reliant on taxpayer-funded care. In this respect, the new law doesn’t do enough. If it did manage to claw back Obamacare’s encroachment on private insurers, it could meaningfully save lives.

At best, the new law’s Medicaid and Obamacare reforms are best understood as a reversion to the trajectory that was in place before the disaster of the pandemic successfully federalized vast swaths of the economy. All in all, even the CBO concedes that the total number of folks on Medicaid in nine years will be just 5 million fewer than the 85 million today, with spending up more than $200 billion per year in 2034. Only in Washington is a $200 billion tax hike considered a pay cut.