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.
These resources support states in documenting how the policy changes in H.R.1 impact affordability, access, and coverage stability in their states.
H.R.1 makes sweeping changes across the Medicaid program, including major shifts in enrollment, eligibility, expenditures, and operations. To understand these impacts, it is imperative that state officials develop a monitoring strategy. This issue brief outlines the strategic case for investment in monitoring, provides a phased action timeline for states to implement monitoring activities, and details potential priority monitoring domains.
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.