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Quick Recap Of House and Senate On Exchange Subsidies and Reform

The Senate is expected to vote Thursday on two proposals. The first is a Democratic proposal for a straight three-year extension of the enhanced Exchange subsidies. It is not expected to gain the 60 votes needed for passage as too few Republicans will join Democrats. But anything is possible right now.

The second is a GOP bill sponsored by Bill Cassidy, R-LA, and Mike Crapo, R-ID. It would not extend the enhanced subsidies, but fund health savings accounts (HSAs) for people who earn up to 700% of the federal poverty level. Those aged 18-49 would get $1,000 and those aged 50-64 would get $1,500. This bill is not expected to reach 60 votes, either, as few Democrats will vote with Republicans. Other compromise bills would extend the subsidy expansions for two years and make some reforms, including income caps, minimum premiums, and fraud protections. These do not appear on the docket, though.

 In the House, Republican leaders say they will vote on healthcare bills next week but not on enhanced subsidies. The caucus now seems to be on a mission to pass a broader reform package to impact affordability for all. The provisions could include site-neutral Medicare payments, pharmacy benefits manager reform, price transparency, expansion of alternative coverage, and health savings account initiatives. It also could fund cost-sharing reductions for the Exchanges.

In the meantime, some moderate Republicans are attempting to force a vote on subsidy extensions by filing a discharge petition. But the moderate GOP petition may be in competition with a Democratic one. Democrats in the House want a three-year extension.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-house-gop-vote-aca-subsidies-extension/ and https://thehill.com/homenews/house/5643481-republicans-obamacare-health-care-revolt/ and https://www.modernhealthcare.com/politics-regulation/mh-gop-aca-subsidies-extension-hsa-pbm/

(Some articles may require a subscription.)

#exchanges #coverage #healthcare

https://thehill.com/homenews/house/5642438-house-gop-health-care-vote-subsidies

— Marc S. Ryan

Stars Health Equity Change Examined

A great Modern Healthcare article on the Trump administration’s proposal to expunge the Excellent Health Outcomes For All (EHO4all) health equity reward just a month before the second measurement year close. I am one of the Stars experts quoted. I make the argument that there are winners and losers when eliminating EHO4all and keeping the Reward Factor for high-performing plans. I think plans with major dual eligible populations and no near-term expectation of obtaining the Reward Factor could have a colorable argument that the rule does not give plans due process of a change. The switchback will cost Medicare billions.

(Article may require a subscription.)

#cms #medicareadvantage #stars #quality

https://www.modernhealthcare.com/insurance/mh-medicare-advantage-star-ratings-centene-molina

Competing Senate Healthcare Bills

Senate Republicans launched competing proposals today to address the healthcare debate. Some want to preserve the enhanced subsidies, while others want the enhanced subsidies to expire and be replaced by direct cash to Americans. GOP Sens. Bernie Moreno, R-OH, and Susan Collins, R-ME, introduced a bill with a two-year extension of the enhancements with some conservative reforms – an income eligibility cap at $200,000, minimum premiums of $25 per month, and fraud reforms. The main competing proposal from HELP Chair Bill Cassidy, R-LA, and Mike Crapo, R-ID, doesn’t extend the subsidies at all. Instead, it would redirect that money into Health Savings Accounts paired with bronze or catastrophic plans on the Exchanges. Certain ACA enrollees earning less than 700 percent of the federal poverty level would receive $1,000 in an HSA if they’re 18 to 49 years old, and $1,500 if they’re 50 to 64.

In other news, a new poll says 57% of Americans approve of the Affordable Care Act (ACA) while 35% oppose. In addition to potentially going without coverage, healthcare policy group finds that many Americans may turn to short-term duration plans. And finally, Democrats are taking on water for a budding Medicaid scandal in Minnesota, under the leadership of Gov. and former Democratic VP candidate Tim Walz.

Additional articles: https://thehill.com/policy/healthcare/5638360-aca-affordable-care-act-obama-care-approval/?tbref=hp and https://www.kff.org/quick-take/as-aca-deadline-approaches-some-price-sensitive-consumers-may-consider-switching-to-short-term-plans/ and https://www.foxnews.com/politics/dr-oz-warns-walz-address-alleged-somali-medicaid-fraud-lose-federal-funding-stop-paying

#exchanges #congress #trump #healthcare #coverage

https://thehill.com/policy/healthcare/5638878-senate-republicans-health-care-proposals

Moderate GOPers Frustrated On Exchange Impasse

Frustration is mounting for moderate GOP lawmakers as the GOP has no defined healthcare plan, and Democrats are capitalizing on the lack of affordability in healthcare and the expiration of enhanced subsidies in the Exchange. Millions will see surging premiums as of January 1 with no action to extend the subsidies. Dozens in the GOP caucus in the House from swing districts face an uncertain future. A few GOP senators are also vulnerable. But so far, House Speaker Mike Johnson, R-LA, bolstered by opposition from conservatives, refuses to guarantee a vote in the House. In the Senate, Majority Leader John Thune, R-SD, did agree to hold a vote and Democrats are pushing a three-year extension. Sixty votes are needed to pass the bill. Democrats would need thirteen GOP defectors. It is a near impossibility.

In other news, MedPage Today talks about the irony that tax-free Health Savings Accounts (HSAs) can pay for parenting workshops, bassinets, and even saunas, but cannot use the funds to pay for premiums under current law. Some Republicans want to send the enhanced subsidies in favor of funding HSAs, but many even among Republicans doubt the federal government can pull off such a swift implementation.

Additional article: https://www.medpagetoday.com/publichealthpolicy/washington-watch/118862 and https://www.fiercehealthcare.com/payers/ahip-presses-aca-subsidy-extension-further-program-integrity-measures

#exchanges #healthcare #coverage #hsas

https://thehill.com/policy/healthcare/5634256-gop-health-care-plans-frustration

Schumer Unveils Three-Year Subsidy Extension

Senate Minority Leader Chuck Schumer, D-NY, unveiled a clean three-year extension of enhanced premium subsidies for a vote next week in the upper chamber. This came after a group of Senate Democrats gained a commitment from Senate Majority Leader John Thine, R-SD, for a subsidy vote when the group agreed to support a bill to reopen the government.

Some Democrats have held talks with centrist Republicans to seek a compromise that would temporarily extend the enhanced subsidies while adding policies such as income eligibility caps, minimum premiums, and anti-fraud measures. This could mean the bill is amended to attract GOP votes to get to 60 votes. Some GOP senators are open to doing so, frustrated with the lack of any real GOP alternative. There are some GOP bills being developed which focus on Health Savings Account support but are not expected to be ready in the Senate next week.

In the House, Reps. Jen Kiggans (R-Va.) and Josh Gottheimer (D-N.J.) led a bipartisan group of 35 House members who released an alternative plan. This proposal would extend enhanced subsidies for two years, lengthen the 2026 open enrollment period until March 19, phase in income caps, and institute anti-fraud policies. The bill also reforms pharmacy benefits managers (PBMs).

House Speaker Mike Johnson, R-LA, and Steve Scalise, R-LA, are working with more conservative members and say they will have a bill in that chamber next week. They say it does not do what Kiggans and Gottheimer have planned.

A poll from healthcare policy group KFF finds that one in three enrollees in the Exchange say they would very likely shop for a cheaper plan if their premiums doubled and one in four would very likely go without insurance. KFF found that 84% want Congress to extend the credits.

In other news, Modern Healthcare reports that healthcare lobbying expenditures spiked 16% to $653 million during the first three quarters of 2025 compared with the same period last year.

Further, the Government Accountability Office (GAO) did find fraud in the Exchanges enrollment system. The analysis found that misused Social Security numbers is a notable source of the fraud risk to monitor. It fraudulently signed up for and renewed coverage. The vast majority of applications were approved. The GAO found that more than 29,000 numbers in 2023 and 68,000 numbers in 2024 were used to receive more than a single year’s worth of coverage, including the tax credits. The agency also identified at least 30,000 applications submitted in plan year 2023 and at least 160,000 applications for 2024 that likely included changes made by brokers or agents that were not authorized. It earlier said that thousands have reported they were fraudulently enrolled or their information changed.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-aca-subsidies-extension-senate-democrats-proposal/ and https://www.modernhealthcare.com/politics-regulation/mh-healthcare-lobbying-2025-phrma-aha/ and https://thehill.com/policy/healthcare/5633501-schumer-to-force-senate-gop-to-vote-on-three-year-extension-of-health-insurance-subsidies/?tbref=hp and https://www.kff.org/public-opinion/poll-1-in-3-aca-marketplace-enrollees-say-they-would-very-likely-shop-for-a-cheaper-plan-if-their-premium-payments-doubled-1-in-4-say-they-very-likely-would-go-without-insurance/ and https://www.modernhealthcare.com/insurance/mh-aca-premiums-blue-cross-michigan/ and https://www.kff.org/public-opinion/2025-kff-marketplace-enrollees-survey/ and https://thehill.com/policy/healthcare/5633353-obamacare-subsidies-aca-kff/ and https://thehill.com/policy/healthcare/5633614-republican-health-bill-johnson-scalise/

(Some articles may require a subscription.)

#exchanges #healthcare #coverage

https://www.fiercehealthcare.com/regulatory/gao-report-highlights-fraud-risk-around-enhanced-aca-subsidies

Will Subsidy Extension Pass?

A Senate vote on a clean, three-year enhanced Exchange subsidy extension is scheduled for next week. And many Republicans are frustrated that their party is divided and no consensus can be reached on any compromise legislation. Any Republican bill would not be ready until after next week. That opens up the possibility that enough Republicans cross the aisle and vote with Democrats to extend the subsidies as is. House Speaker Mike Johnson, R-LA, has not yet committed to bring up the bill, but Democrats and some moderate Republicans could force a vote through a discharge petition.

Given the lack of a real Republican bill, GOP lawmakers in both chambers are coming around to a temporary extension of enhanced Exchange subsidies. Conservative House and Senate Republicans either want fundamental reform or no action to extend the enhanced subsidies. Moderate Republicans in the House want either a clean extension or small changes to address conservative concerns regarding uncapped subsidies, no premiums for some, and fraud.

In the Senate, Republicans favor a variety of Health Saving Account expansions, including a proposal from HELP Committee Chair Bill Cassidy that would send the difference between base and enhanced subsidies to certain Americans to buy insurance on their own or use for costs. Sen. Josh Hawley, R-MO, pitched a plan to allow taxpayers to deduct all out-of-pocket medical expenses up to $25,000 per individual or dependent. 

The HELP Committee held an affordability hearing today that looked very much like one held in Senate Finance recently. Fireworks flew between the parties.

Moderate voices in the GOP, especially from swing districts, worry that affordability of healthcare will dominate midterm elections in 2026.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-aca-subsidy-extension-republicans-congress/ and https://thehill.com/newsletters/health-care/5632682-bipartisan-obamacare-deal-remains-out-of-reach-in-senate-hearing/

(Some articles may require a subscription.)

#exchanges #healthcare #coverage

https://thehill.com/policy/healthcare/5632583-republicans-divided-aca-subsidies

Nursing Home Staffing Rule In Dustbin

The controversial rule seeking to impose nursing home staffing requirements has been officially repealed by the federal government after a judge struck down the Biden administration provision. The rule would have meant huge costs for the industry and actually either forced the shutter of smaller firms or led them to sell out to massive consolidators in the industry. The rule was a political sop to the unions as well.

Additional article: https://www.modernhealthcare.com/politics-regulation/mh-cms-nursing-home-staffing-mandate-repealed/

(Some articles may require a subscription.)

#nursinghomes #staffing #medicaid #medicare

https://www.fiercehealthcare.com/regulatory/hhs-closes-book-controversial-nursing-home-staffing-mandate

Exchange Subsidy Debate Still Dominates Hill

The Exchange subsidy debate continues to dominate Capitol Hill.

Sen. Amy Klobuchar, D-MN, predicted Sunday that the Senate will hold a vote on extending Exchange subsidies. “That vote will happen. And whether it will pass is in the hands of Donald Trump and the Republicans,” Klobuchar told CNN. Senate Majority Leader John Thune, R-SD, has committed to a vote, while House Speaker Mike Johnson, R-LA, has not.

House Minority Leader Hakeen Jeffries, D-NY, is pressing centrist Republicans to help Democrats extend the tax credits before they expire at the end of the month by signing on to his discharge petition to force a vote in the House. Moderate Republicans in the House say they have their own discharge petition but are waiting to see what the Senate does.

Many are critical of President Trump’s equivocation on the subsidies – in one breath he is ready to present an extension and mini-reform plan and in another backing away and saying he does not want to extend subsidies. Centrists in the GOP want a clean extension perhaps with some small conservative tweaks on income caps, minimum premiums, and fraud protections. But conservatives want a fairly major remake of healthcare, migrating to individually controlled  subsidies for coverage.

Former George W. Bush White House deputy chief of staff and GOP strategist Karl Rove said Republicans need to have a healthcare agenda ahead of the midterm elections or they’ll be in “deep trouble.”

Additional articles: https://thehill.com/policy/healthcare/5627171-klobuchar-predicts-aca-senate-vote/ and https://thehill.com/homenews/house/5628255-obamacare-tax-credits-extension/ and https://www.politico.com/news/2025/12/01/trump-health-care-subsidies-congress-00671172

#exchanges #healthcare #coverage

https://thehill.com/homenews/campaign/5627604-gop-health-care-agenda

Populist Trump Attacks Health Plans

President Donald Trump has turned to attacking health plans in the wake of a concerted effort from Democrats accusing him and the GOP of not doing enough to tackle affordability. Trump was thought to be preparing an enhanced subsidy extension plan, but it is either delayed or won’t happen due to opposition from GOP conservatives in Congress. Trump is said to have supported a two-year extension with some reforms of the enhancements along with introducing subsidies for Health Savings Accounts for some to use.

 In a recent social media post he directed his ire on healthcare affordability to health plans, saying: “The only healthcare I will support or approve is sending the money directly back to the people, with nothing going to the big, fat, rich insurance companies, who have made $trillions, and ripped off America long enough.” Of course, that is not true.

But Trump may have the pulse of the nation. A recent poll determined 63% of those surveyed saying insurance companies were the most responsible for medical debt and 76% saying they want the country to switch to a different health insurance system in which they can be unemployed or self-employed and still remain insured. And 74% in a poll said they were in favor of Congress extending the credits rather than letting them expire. But when asked if they should be extended when reminded they were enhanced during the COVID pandemic, support drops dramatically.

But the public is not aware of the fact that health plan margins fell to 0.8% last year. Another analysis found negative earnings from 2019 to 2024, with other healthcare entities doing much better.

#healthplans #trump #populism #exchanges #coverage #healthcare

https://thehill.com/policy/healthcare/5621976-trump-blames-insurers-healthcare

— Marc S. Ryan

What Is On GOP Menu For Subsidies?

A good article in The Hill on Thanksgiving breaking down the GOP dilemma on what to do with the Exchange enhanced subsidy expiration that is looming. The issue pits moderate Republicans against conservative ones. There are competing proposals across the House and Senate.

The dilemma: Extend the subsidies and endorse Obamacare or let the subsidies expire and deal with the electoral fallout in 2026. This could be major in dozens of moderate Republican swing districts in the House and several seats in the Senate.

Here are some bills percolating on the Republican side:

Moderates in both parties in House:

One bill would extend the enhanced subsidies for two years but make some changes to assuage conservatives. Those earning less than $200,000 per year for a family of four would keep their subsidies and those earning between $200,000 and $300,000 for a family of four would face a phaseout. Fraud measures would be adopted as well. The bill would extend open enrollment to May 15 given the mass confusion over what subsidies will or will not be and the sticker shock of published premiums. 

Another bipartisan group in the House back a two-year subsidy extension with an income cap. It is partially paid for by cutting Medicare Advantage overpayments.

Another moderate bill backs a one-year extension.

Senate HELP Chair Bill Cassidy, R-LA:  

The plan from Cassidy would let the enhanced subsidies expire. Congress would then deposit money directly into health savings accounts (HSAs) for people who buy high-deductible plans on the Exchanges. The original subsidies would still go toward marketplace premiums. His idea takes advantage of a change made in the One Big Beautiful Bill Act (OBBBA), which allowed Bronze plans to be eligible for HSAs. Bronze plans feature lower premiums but high deductibles and only 60 percent coverage for medical expenses. HSAs can’t be used to pay for monthly premiums under current law. Republicans like the HSA idea, but there are many critics of and problems with the proposal. They argue it does not provide affordable access. 

Sen Rick Scott, R-FL:

Scott’s legislation centers on HSAs and would let the enhanced subsidies expire. Scott’s bill lets states submit a waiver to the federal government to replace the base Exchange premium tax credits and instead fund “HSA-style Trump Health Freedom Accounts.” Unlike traditional HSAs, people could use the funds to pay for both premiums and health expenses. In addition, states could waive certain provisions of the Affordable Care Act, including mandated benefits, among other things. The HSAs could be used for any type of health insurance plan, including short-term plans. Again, Republicans like the individual purchase idea, but the proposal could undermine the stability further in the Exchanges by increasing risk in the program as healthier people leave. It would impact sicker people receiving coverage.

The Trump non-plan:

The president was said to be on the verge of offering a plan that would temporarily extend the enhanced subsidies, potentially for two years, while incorporating income caps, minimum premiums, and fraud protections. The plan also would have HSA contributions and other incentives for enrollees to choose a high-deductible plan.

Trump appears to have backed off presenting something due to opposition from hardline conservatives in Congress.

Let’s hope for a responsible compromise to help Americans with healthcare this holiday season. It is not their fault that things have become so unaffordable.

Happy Thanksgiving!

#exchanges #healthcare #coverage

https://thehill.com/policy/healthcare/5624197-aca-subsidies-republican-options

— Marc S. Ryan