On July 4, 2025, the federal budget reconciliation bill, H.R.1, was signed into law, enacting major structural reforms to Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act Marketplaces. These changes, including a $911 billion reduction in federal Medicaid spending over the next 10 years, significantly reshape the operational and financial landscape of the health coverage system, with far-reaching implications for program enrollment, expenditures, and administration, immediately and in the years ahead.
H.R.1 and federal regulations will significantly reshape Affordable Care Act Marketplace programs and affordability. These resources support states with implementation.
H.R.1 makes significant changes to how individuals enroll and stay enrolled in the Affordable Care Act Marketplaces, with two of those changes taking effect for plan year (PY) 2028—the end of both auto-reenrollment and advanced premium tax credits during pending verification. In advance of these changes, State-Based Marketplaces (SBMs) can leverage the upcoming open enrollment period beginning in fall 2026 to build capacity, test approaches, and identify what works before the stakes rise for PY 2028, to help ensure eligible enrollees remain covered without disruptions to care. This expert perspective highlights preparatory actions that SBMs can take, including operational and communications pilots.
As the 2026 open enrollment period is underway, understanding the impact of the scheduled expiration of the enhanced premium tax credits and other recent federal legislative and regulatory policy changes on Marketplace coverage uptake is crucial. State-Based Marketplaces (SBMs) have historically provided enrollment updates throughout open enrollment to offer early insights into enrollment trends and the challenges consumers may face. This expert perspective serves as a one-stop resource for tracking real-time 2026 SBM open enrollment data and SHADAC will continue to update this tracker throughout open enrollment to reflect the latest developments in SBM reporting.
Changes to the Marketplaces ushered in by recent federal policy actions and the scheduled expiration of the enhanced premium tax credits will raise premiums and may ultimately lead consumers to forgo coverage. Targeted surveys can be a quick and inexpensive way for State-Based Marketplaces (SBMs) to better understand why consumers are not reenrolling in coverage. This expert perspective includes sample survey questions that SBMs could send during or after open enrollment to gather more information from consumers, including an example from Maryland, and general guidance on question language, timing, and more.
Recent federal policy actions, including H.R.1, the 2025 Marketplace Integrity and Affordability Rule, and the pending expiration of the enhanced premium tax credits, are poised to significantly reshape the health insurance landscape across all states. State-Based Marketplaces (SBMs) can be at the forefront of documenting how federal policy changes impact affordability, access, and coverage stability in their states. This issue brief outlines four priority strategies for SBMs, including a core set of recommended measures, long-term impact metrics, incorporating lived experiences through consumer surveys, and research and evaluation partnerships.
H.R.1, signed into law on July 4, makes dramatic changes to the Medicaid and Marketplace coverage landscape. These changes include provisions that scale back access to health coverage for many lawfully residing non-citizens, estimated to leave 1.3 million more immigrants uninsured. This expert perspective describes the provisions, which eliminate the availability of premium tax credits (PTCs) and federally-funded Medicaid and CHIP coverage for many non-citizens who have been eligible for these programs for years, and eliminate PTCs for the lowest income, lawfully present non-citizens who are subject to a waiting period before they qualify for Medicaid or CHIP.
As the open enrollment period for plan year 2026 approaches, health insurance Marketplaces face a rapidly shifting policy environment. These changes will influence the way Marketplaces engage with enrollees, community partners, and stakeholders. This toolkit is designed to help State-Based Marketplaces maintain trust with enrollees and stakeholders; communicate clearly and effectively; prepare enrollees for upcoming changes; and help enrollees maintain coverage and access care. The toolkit includes content that states can customize to reflect their voice and policy context.
This Excel tool provides an integrated view of implementation dates for Medicaid, the Children’s Health Insurance Program, Marketplace, and Medicare provisions in the budget reconciliation law, H.R.1. Because of interdependencies with the budget reconciliation provisions, policies in the Marketplace Integrity and Affordability final rule of June 25, 2025, are also included in this timeline. This tool is intended to support states in (1) planning for timely implementation of reconciliation-driven health policy changes, and (2) effectively communicating potential impacts to communities and key stakeholders.
The federal policy changes included in the budget reconciliation bill, as well as the recently finalized 2025 Marketplace Integrity and Affordability Rule, will significantly impact many essential State-Based Marketplace (SBM) functions and result in significant coverage losses. As the federal policy bills were being considered, SHADAC tracked states’ estimates of the impacts of the federal policy changes and the expiration of the enhanced premium tax credits on SBM consumers. The estimates collected in this expert perspective illustrate how states worked to assess the likely effects of major federal changes to their SBMs.
On Thursday, July 10, State Health and Value Strategies hosted a webinar for State-Based Marketplace and Division of Insurance officials. On July 4, the president signed the reconciliation budget bill into law, starting the clock on a number of changes to Marketplace coverage and premium tax credit eligibility. Just two weeks earlier, the Centers for Medicare & Medicaid Services finalized its Program Integrity rule that also creates new requirements for Marketplaces. During the webinar, SHVS’ experts discussed the immediate changes that states are facing and what steps to take in the coming days and weeks.