A from 42 states and the District of Columbia offers insights into key policy decisions state officials face as the Jan. 1, 2027, deadline for implementing the work requirement nears. Lingering questions include which diseases and illnesses will qualify Medicaid beneficiaries for exemptions and how to automate compliance verification. 

Federal guidance is not expected to be released until June. But some states are moving forward with their own definitions of “medical frailty,” which under congressional Republicans’ One Big Beautiful Bill Act will allow Medicaid enrollees to escape the requirement.

The law, President Donald Trump’s signature domestic achievement, revamps Medicaid in more than 40 states that, along with Washington, D.C., fully or partially expanded the program for low-income people to cover adults without children who don’t get insurance through a job. While most adult Medicaid beneficiaries already work or are disabled, caregivers for other people, or in school, many Republicans contend that people enrolled in the program who don’t work sap resources that ought to support low-income children, pregnant women, and disabled people.

gained Medicaid coverage from the expansion, created by the Affordable Care Act — a law that most Republicans still oppose.

The new work rules require that a person be a student at least part-time or work or participate in other qualifying activities, such as community service, for at least 80 hours each month. The requirement could potentially reshape who is eligible for Medicaid and applies to people who are already enrolled.

The Congressional Budget Office will reduce federal Medicaid spending by about $326 billion over 10 years. The agency also estimates that 4.8 million more people will be uninsured in 2034 because of the work requirement.

 “A lot of states are working on a super-condensed timeline,” said Amaya Diana, a policy analyst at Â鶹ŮÓÅ who worked on the survey. They are “still making these big decisions with less than a year before implementation.”

Â鶹ŮÓÅ is a health information nonprofit that includes Â鶹ŮÓÅ Health News.

The law permits short exemptions from work requirements for enrollees experiencing certain hardships — natural disasters, residing in a county with a high unemployment rate, admission to a hospital or nursing home, or having to travel for an extended period to obtain medical care.

While 28 states and Washington, D.C., will offer hardship exemptions, three of those states won’t adopt all four exemptions allowed by the law and two — Iowa and Indiana — don’t plan to adopt any.

People can also be exempted from the work requirements if they are “medically frail.” But the federal government has not told states how to define that term or how to determine whether an enrollee falls into the category.

The survey showed that 21 states, as of March, had not defined medical frailty. Nebraska, which is implementing its work requirement May 1, recently issued a list of thousands of health conditions that could qualify enrollees as “frail” and exempt them from working.

Some states plan to allow patients to self-attest to medical frailty, while others will require confirmation by a medical professional. The most common way of verifying medical frailty, which will be used in just over 30 states, is by examining Medicaid claims data.

Mehmet Oz, administrator for the federal Centers for Medicare & Medicaid Services, told Â鶹ŮÓÅ Health News in an interview this week that “we don’t like self-attesting” and that “documentation is critical.”

Many beneficiaries and their advocates have expressed concerns about losing coverage for administrative reasons. When Arkansas briefly implemented Medicaid work rules, for instance, most lost coverage not because they did not meet the requirements but for failing to correctly submit paperwork in time.

Six states plan to use AI to assist with the work requirement implementation in some way, such as for document processing or comparing beneficiary data from different sources, Â鶹ŮÓÅ found. Two states, Maryland and New Mexico, plan to use AI to analyze claims data.

Three states — Arkansas, Missouri, and Oklahoma — plan to use AI to interact directly with people on Medicaid and assist them with identifying and uploading verification documents and data.

Adults on Medicaid will have to reverify that they’re working, or that they’re exempt from the requirement, at least every six months. Some states plan to check quarterly.

When possible, states must use available data sources to verify exemptions or compliance with work requirements.

For example, data from the National Student Clearinghouse will be used by about 10 states to verify school attendance. Some states also plan to tap sources including the Department of Veterans Affairs, AmeriCorps, and service commissions.

But more than half of states told Â鶹ŮÓÅ’s researchers that they have insufficient time to add new data sources and cited ongoing costs as a challenge.

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Still, 69% of those enrolled last year signed up again this year, often for less generous coverage. About 9% said they had to forgo insurance, according to the survey by Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

The Â鶹ŮÓÅ poll revisited the people who responded to of Affordable Care Act enrollees during open enrollment for ACA plans.

Steve Davis, a 64-year-old retired car salesman in Rogersville, Tennessee, who participated in both polls, said he was looking at an annual premium of about $14,000 to renew his ACA coverage this year. He didn’t qualify for enough of a tax credit to defray the cost, he said, after Congress gridlocked on an extension of more-generous subsidies put in place under President Joe Biden.

But things worked out for Davis. He landed a job at a convenience store that came with insurance, with his share costing about $100 more a month than the $300 he paid for an ACA plan last year, before the enhanced tax credits expired.

“As it happened, the Lord provided and my insurance kicked in through my employer,” he told Â鶹ŮÓÅ Health News.

In the November survey, many respondents were not sure what they would do for their health insurance in the coming year.

Some were waiting to see whether Congress would extend the enhanced premium subsidies, which had helped many people get lower-cost — or even zero-cost — health premiums.

Congress’ inaction left some consumers in a bind.

Now, the new poll found, affordability issues are hitting home as the midterm election approaches. And that might play a role in competitive districts, creating headwinds for Republicans.

Midterm Signals

Across all respondents who were registered to vote, the poll found more than half place “a lot” of blame for rising costs on Republicans in Congress (54%), with a similar share putting the same level of blame on President Donald Trump (53%). A smaller group placed a lot of the blame on congressional Democrats (34%). Among independents, a group expected to be a key factor in many districts, the percentages putting a lot of the blame on the GOP (56%) and Trump (58%) were higher.

Among Republicans, 60% placed a lot of the blame on Democrats in Congress.

“Those who have marketplace coverage, who remained on it, they’re really struggling with health care costs,” said Lunna Lopes, senior survey manager for Â鶹ŮÓÅ.

While more than half (55%) of returning ACA enrollees said they will have to pare back on other household expenses to cover health care costs, about 17% said they might not be able to continue paying insurance premiums throughout the year.

Overall, 80% of those who reenrolled for 2026 said their premiums, deductibles, or other costs are higher this year than last, with 51% saying they are “a lot higher.”

About three-quarters of ACA enrollees in the survey who were registered voters said the cost of health care will have an impact on their decision to vote — and on which party’s candidate they support.

Democrats were more than twice as likely as Republicans to say those costs will have a major impact on their decision.

“Democrats seem particularly more energized by health care costs than their Republican counterparts,” Lopes said.

Enrollment Tally Down

Data released Jan. 28 by federal officials showed that about 23 million people enrolled in Obamacare plans across the federal healthcare.gov marketplace and those run by states, about 1.2 million fewer than in 2025.

But it isn’t yet known how many are paying their monthly premiums on time, and many analysts expect overall enrollment numbers to fall as that data becomes available in the coming months.

For most people, having to pay more for premiums this year was mainly due to the expiration of the enhanced tax cuts, pollsters noted. Because the subsidies that remain are less generous, households have to pay more of their income toward coverage. Congressional inaction also meant the restoration of an income cap for subsidies at four times the poverty level, or $62,600 for an individual, sticking people like Davis with higher bills.

Not everyone saw increases.

Matthew Rutledge, a 32-year-old substitute teacher in Apple Valley, California, who participated in both Â鶹ŮÓÅ polls, said he qualified as low-income and his subsidies fully offset his monthly premium payment, just as they did last year. He does have copayments when he sees a doctor or accesses other medical care, but he told Â鶹ŮÓÅ Health News that “as long as the premium doesn’t go up, I’m fine with it.”

Rising premiums are fueled by a variety of factors, including hospital costs, doctors’ services, and the prices of drugs.

To lower premiums, insurers offer plans with higher deductibles or copayments. In the ACA, plans with lower premiums but higher deductibles are called “catastrophic” or “bronze” plans. “Silver” plans generally balance premiums and out-of-pocket spending, while the highest-premium plans with lower deductibles are “gold” or “platinum.”

About 28% of those who stayed in the ACA marketplaces switched plans, the pollsters noted.

One 56-year-old Texas man told pollsters that his family’s income exceeded the cap for subsidies, so they switched down from a gold plan to a bronze. “Even doing that, our premiums are three times what they were in 2025, with lower plan features and a higher deductible,” he said, according to a Â鶹ŮÓÅ poll news release.

For some, reenrolling was not a viable option.

In addition to the 9% who said they are now uninsured, about 5% said they switched to some type of non-ACA coverage.

Some people, like Davis, landed job-based coverage, while others found they qualified for Medicaid, the joint state-federal program for low-income residents.

Such churn in and out of ACA coverage is not unusual, Lopes noted. “People get a job. They get married. They age into Medicare,” the program for older or disabled people, she said.

The poll highlighted that many people dropping coverage were younger, between 18 and 29. About 14% of people in that range now say they are uninsured. 

That’s not surprising, given that younger people tend to use health coverage less. ACA insurers said one reason they raised premiums this year was because they expected more young or healthy people to drop out, leaving them with a higher share of older, more costly enrollees. Among those 50 or older, the poll found that only 7% are now uninsured.

GOP critics of the now-expired enhanced subsidies say they were always meant to be temporary. Extending them would have cost about $350 billion from 2026 to 2035, .

But not extending them means more people will become uninsured. The CBO said the extension would have meant 3.8 million more people having insurance coverage in 2035.

Â鶹ŮÓÅ pollsters, in February and early March, surveyed 1,117 U.S. adults, more than 80% of the ACA enrollees originally polled in November, online and by telephone. The margin of error is plus or minus four percentage points for the full sample.

Are you struggling to afford your health insurance? Have you decided to forgo coverage?  to contact Â鶹ŮÓÅ Health News and share your story.

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Premiums for job-based health insurance rose 6% in 2025 to an average of $26,993 a year for family coverage, according to an annual survey of employers released Oct. 22 by Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

It’s the first time in two decades that the cost of covering a family of four has risen by 6% or more for three consecutive years, data from Â鶹ŮÓÅ shows.

Over the last five years, the average premium for family coverage has increased by 26%, compared with a 29% increase in workers’ wages and nearly 24% growth in inflation. The average cost for family coverage is now about the same as

The average annual premium for an individual health plan provided by employers increased by 5% to $9,325 — nearly $3,000 higher than in 2016, according to the survey.

“It’s a concern as health costs just keep going up,” said Eric Trump, controller at Steve Reiff Inc., a small company in South Whitley, Indiana, that specializes in sandblasting and painting heavy equipment.

Trump, who is not related to President Donald Trump, said his company’s health insurance costs rose 8% for the 2026 fiscal year — roughly the same as they have in the last few years.

Workers at Reiff pay about half the cost of their health coverage. About half of its 20 current employees decline the insurance because they get coverage through a family member or choose to go uninsured, he said. “There’s not a lot we can do as we don’t have enough employees to spread out the costs.”

Most people with job-based insurance contribute to the cost of their premiums, with the average worker this year contributing $1,440 for individual coverage or $6,850 for family coverage.

Over time, more workers have paid increasingly higher deductibles, the amount they must spend out-of-pocket on medical services before their insurer pitches in. More than one‑third of covered workers are enrolled in a plan with a deductible of $2,000 or more for an individual. The share of workers with such a plan has increased 32% over the last five years and 77% over the last 10 years, the report said.

Rising drug and hospital costs as major culprits for rising health insurance costs, and neither shows signs of ebbing.

“Early reports suggest that cost trends will be higher for 2026, potentially leading to higher premium increases unless employers and plans find ways to offset higher costs through changes to benefits, cost sharing, or plan design,” the Â鶹ŮÓÅ survey said.

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Millions of people are expected to lose health insurance in the coming years as a result of the tax cut legislation Trump signed this month, leaving them with fewer protections from large bills if they get sick or suffer an accident.

At the same time, significant increases in health plan premiums on state insurance marketplaces next year will likely push more Americans to either drop coverage or switch to higher-deductible plans that will require them to pay more out-of-pocket before their insurance kicks in.

Smaller changes to federal rules are poised to bump up patients’ bills, as well. New federal guidelines for covid-19 vaccines, for example, will to stop covering the shots for millions, so if patients want the protection, some may have to pay out-of-pocket.

The new tax cut legislation will also raise the cost of certain doctor visits, requiring copays of up to $35 for some Medicaid enrollees.

And for those who do end up in debt, there will be fewer protections. This month, the Trump administration secured permission from a federal court to that would have removed medical debt from consumer credit reports.

That puts Americans who cannot pay their medical bills at risk of lower credit scores, hindering their ability to get a loan or forcing them to pay higher interest rates.

“For tens of millions of Americans, balancing the budget is like walking a tightrope,” said Chi Chi Wu, a staff attorney at the National Consumer Law Center. “The Trump administration is just throwing them off.”

White House spokesperson Kush Desai did not respond to questions about how the administration’s health care policies will affect Americans’ medical bills.

The president and his Republican congressional allies have brushed off the health care cuts, including hundreds of billions of dollars in Medicaid retrenchment in the mammoth tax law. “You won’t even notice it,” at the White House after the bill signing July 4. “Just waste, fraud, and abuse.”

But consumer and patient advocates around the country warn that the erosion of federal health care protections since Trump took office in January threatens to significantly undermine Americans’ financial security.

“These changes will hit our communities hard,” said Arika Sánchez, who oversees health care policy at the nonprofit New Mexico Center on Law and Poverty.

Sánchez predicted many more people the center works with will end up with medical debt. “When families get stuck with medical debt, it hurts their credit scores, makes it harder to get a car, a home, or even a job,” she said. “Medical debt wrecks people’s lives.”

For Americans with serious illnesses such as cancer, weakened federal protections from medical debt pose yet one more risk, said Elizabeth Darnall, senior director of federal advocacy at the American Cancer Society’s Cancer Action Network. “People will not seek out the treatment they need,” she said.

Trump promised a rosier future while campaigning last year, and “expand access to new Affordable Healthcare.”

Polls suggest voters were looking for relief.

About 6 in 10 adults — Democrats and Republicans — say they are worried about being able to afford health care, according to , outpacing concerns about the cost of food or housing. And medical debt remains a widespread problem: As many as 100 million adults in the U.S. are burdened by some kind of health care debt.

Despite this, key tools that have helped prevent even more Americans from sinking into debt are now on the chopping block.

Medicaid and other government health insurance programs, in particular, have proved to be a powerful economic backstop for low-income patients and their families, said Kyle Caswell, an economist at the Urban Institute, a think tank in Washington, D.C.

Caswell and other , for example, that Medicaid expansion made possible by the 2010 Affordable Care Act led to measurable declines in medical debt and improvements in consumers’ credit scores in states that implemented the expansion.

“We’ve seen that these programs have a meaningful impact on people’s financial well-being,” Caswell said.

Trump’s tax law — which will slash more than $1 trillion in federal health spending over the next decade, mostly through Medicaid cuts — is expected to leave 10 million more people without health coverage by 2034, according to the from the nonpartisan Congressional Budget Office. The tax cuts, which primarily benefit wealthy Americans, will add $3.4 trillion to U.S. deficits over a decade, the office calculated.

The number of uninsured could spike further if Trump and his congressional allies don’t renew additional federal subsidies for low- and moderate-income Americans who buy health coverage on state insurance marketplaces.

This aid — enacted under former President Joe Biden — lowers insurance premiums and reduces medical bills enrollees face when they go to the doctor or the hospital. But unless congressional Republicans act, those subsidies will expire later this year, leaving many with bigger bills.

Federal debt regulations developed by the Consumer Financial Protection Bureau under the Biden administration would have protected these people and others if they couldn’t pay their medical bills.

The agency issued rules in January that would have removed medical debts from consumer credit reports. That would have helped an estimated 15 million people.

But the Trump administration chose not to defend the new regulations when they were challenged in court by debt collectors and the credit bureaus, who argued the federal agency had exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.

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Julie Rovner Â鶹ŮÓÅ Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of Â鶹ŮÓÅ Health News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

Much of the hubbub in health care this year has been focused on Medicaid, which faces dramatically reduced federal funding as the result of the huge budget bill signed by President Donald Trump earlier this month. But now the attention is turning to the Affordable Care Act, which is facing some big changes that could cost many consumers their health coverage as soon as 2026.

Meanwhile, changes to immigration policy under Trump could have an outsize impact on the nation’s health care system, both by exacerbating shortages of health workers and by eliminating insurance coverage that helps keep some hospitals and clinics afloat.

This week’s panelists are Julie Rovner of Â鶹ŮÓÅ Health News, Julie Appleby of Â鶹ŮÓÅ Health News, Jessie Hellmann of CQ Roll Call, and Alice Miranda Ollstein of Politico.

Panelists

Julie Appleby Â鶹ŮÓÅ Health News Read Julie's stories.

Jessie Hellmann CQ Roll Call

Alice Miranda Ollstein Politico

Among the takeaways from this week’s episode:

• Many Americans can expect their health insurance premiums to rise next year, but those rate hikes could be even bigger for the millions who rely on ACA health plans. To afford such plans, most consumers rely on enhanced federal government subsidies, which are set to expire — and GOP lawmakers seem loath to extend them, even though many of their constituents could lose their insurance as a result.
• Congress included a $50 billion fund for rural health care in Trump’s new law, aiming to cushion the blow of Medicaid cuts. But the fund is expected to fall short, especially as many people lose their health insurance and clinics, hospitals, and health systems are left to cover their bills.
• Abortion opponents continue to claim the abortion pill mifepristone is unsafe, more recently by citing a problematic analysis — and some lawmakers are using it to pressure federal officials to take another look at the drug’s approval. Meanwhile, many Planned Parenthood clinics are bracing for an end to federal funding, stripping money not only from busy clinics where abortion is legal but also from clinics that provide only contraception, testing for sexually transmitted infections, and other non-abortion care in states where the procedure is banned.
• And as more states implement laws enabling doctors to opt out of treatments that violate their morals, a pregnant woman in Tennessee says her doctor refused to provide prenatal care, because she is unmarried.

Also this week, Rovner interviews Jonathan Oberlander, a Medicare historian and University of North Carolina health policy professor, to mark Medicare’s 60th anniversary later this month.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: Â鶹ŮÓÅ Health News’ “Republicans Call Medicaid Rife with Fraudsters. This Man Sees No Choice but To Break the Rules,” by Katheryn Houghton.  

Julie Appleby: NPR’s “,” by Rachel Treisman.  

Jessie Hellmann: Roll Call’s “,” by Ariel Cohen.  

Alice Miranda Ollstein: The Associated Press’ “,” by Amanda Seitz and Jonel Aleccia.  

Also mentioned in this week’s podcast:

• Â鶹ŮÓÅ Health News’ “Insurers and Customers Brace for Double Whammy to Obamacare Premiums,” by Julie Appleby.
• The Congressional Budget Office’s “.”
• The CBO’s “.”
• Â鶹ŮÓÅ’s “,” by Grace Sparks, Shannon Schumacher, Julian Montalvo III, Ashley Kirzinger, and Liz Hamel.
• The Washington Post’s “,” by Glenn Kessler.

Credits

To hear all our podcasts, click here.

And subscribe to Â鶹ŮÓÅ Health News’ “What the Health?” on , , , or wherever you listen to podcasts.

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Insurers want higher premiums to cover the usual culprits — rising medical and labor costs and usage — but are tacking on extra percentage point increases in their 2026 rate proposals to cover effects of policy changes advanced by the Trump administration and the Republican-controlled Congress. One key factor built into their filings with state insurance departments: uncertainty over whether Congress allows more generous, covid-era ACA tax subsidies to expire at the end of December.

“The out-of-pocket change for individuals will be immense, and many won’t actually be able to make ends meet and pay premiums, so they will go uninsured,” said JoAnn Volk, co-director of the Center on Health Insurance Reforms at Georgetown University.

Especially if the higher subsidies expire, insurance premiums will be among the first financial pains felt by health care consumers after policy priorities put forward by President Donald Trump and the GOP. Many other changes — such as additional paperwork requirements and spending cuts to Medicaid — won’t occur for at least another year. But spiking ACA premiums, as the nation heads into key midterm elections, invites political pushback. Some on Capitol Hill are exploring ways to temper the subsidy reductions.

“I am hearing on both sides — more from Republicans, but from both the House and Senate” — that they are looking for levers they can pull, said Pennsylvania-based insurance broker Joshua Brooker, who follows legislative actions as part of his job and sits on several insurance advisory groups.

In initial filings, insurers nationally are seeking a median rate increase — meaning half of the proposed increases are lower and half higher — of 15%, for the Peterson-Â鶹ŮÓÅ Health System Tracker covering 19 states and the District of Columbia. Â鶹ŮÓÅ is a national health information nonprofit that includes Â鶹ŮÓÅ Health News.

That’s up sharply from the last few years. For the 2025 plan year, for example, Â鶹ŮÓÅ found that the median proposed increase was 7%.

Health insurers “are doing everything in their power to shield consumers from the rising costs of care and the uncertainty in the market driven by recent policy changes,” wrote Chris Bond, a spokesperson for AHIP, the industry’s lobbying group. The emailed response also called on lawmakers “to take action to extend the health care tax credits to prevent skyrocketing cost increases for millions of Americans in 2026.”

Neither the White House nor the Department of Health and Human Services responded to requests for comment.

These are initial numbers and insurance commissioners in some states may alter requests before approval.

Still, “it’s the biggest increase we’ve seen in over five years,” said analysis co-author Cynthia Cox, a Â鶹ŮÓÅ vice president and director of its Program on the ACA.

Premiums will vary based on where consumers live, the type of plan they choose, and their insurer.

For example, Maryland insurers have requested increases ranging from 8.1% to 18.7% for the upcoming plan year, by Georgetown University researchers. A much larger swing is seen in New York, where one carrier is asking for less than a 1% increase, while another wants 66%. Maryland rate filings indicated the average statewide increase would shrink to 7.9% from 17.1% — if the ACA’s enhanced tax credits are extended.

Most insurers are asking for 10% to 20% increases, the Â鶹ŮÓÅ report says, with several factors driving those increases. For instance, insurers say underlying medical costs — including the use of expensive obesity drugs — will add about 8% to premiums for next year. And most insurers are also adding 4% above what they would have charged had the enhanced tax credits been renewed.

But rising premiums are just part of the picture.

A bigger potential change for consumers’ pocketbooks hinges on whether Congress decides to extend more generous tax credits first put in place during President Joe Biden’s term as part of the American Rescue Plan Act in 2021, then extended through the Inflation Reduction Act in 2022.

Those laws raised the subsidy amounts people could receive based on their household income and local premium costs and removed a cap that had barred higher earners from even partial subsidy assistance. Higher earners could still qualify for some subsidy but first had to toward the premiums.

Across the board, but especially among lower-income policyholders, bigger subsidies in ACA plans.

But they’re also costly.

A permanent extension over the next decade, according to the Congressional Budget Office.

Such an extension was left out of the policy law Trump signed on July 4 that he called the “One Big Beautiful Bill.” Without action, the extra subsidies will expire at the end of this year, after which the tax credits will revert to less generous pre-pandemic levels.

That means two things: Most enrollees will be on the hook to pay a larger share of their premiums as assistance from federal tax credits declines. Secondly, people whose household income exceeds — $84,600 for a couple or $128,600 for a family of four this year — won’t get any subsidies at all.

If the subsidies expire, policy experts estimate, the average amount people pay for coverage . In some states, ACA premiums could double.

“There will be sticker shock,” said Josh Schultz, strategic engagement manager at Softheon, a New York consulting firm that provides enrollment, billing, and other services to about 200 health insurers, many of which are bracing for enrollment losses.

And enrollment could fall sharply. that the combination of expiring tax credits, the Trump law’s new paperwork, and other requirements will result in ACA enrollment dropping by as much as 57%.

According to Â鶹ŮÓÅ, insurers added premium increases of around 4% just to cover the expiration of the enhanced tax credits, which they fear will lead to lower enrollment. That would further raise costs, insurers say, because people who are less healthy are more likely to grit their teeth and reenroll, leaving insurers with a smaller, but sicker, pool of members.

Less common in the filings submitted so far, but noticeable, are increases pegged to Trump administration tariffs, Cox said.

“What they are assuming is tariffs will drive drug costs up significantly, with some saying that can have around a 3-percentage-point increase” in premiums as a result, she said.

Consumers will learn their new premium prices only late in the fall, or when open enrollment for the ACA begins on Nov. 1 and they can start shopping around.

Congress could still act, and discussions are ongoing, said insurance broker Brooker.

Some lawmakers, he said, are consulting with the CBO about the fiscal and coverage effects of various scenarios that don’t extend the subsidies as they currently exist but may offer a middle ground. One possibility involves allowing subsidies for families earning as much as five or six times the poverty level, he said.

But any such effort will draw pushback.

Some conservative think tanks, such as the Paragon Health Institute, to fudge their incomes to qualify and led to other types of fraud, such as brokers signing people up for ACA plans without authorization.

But others note that many consumers — Democratic and Republican — have come to rely on the additional assistance. Not extending it could be risky politically. lived in Republican congressional districts, and 76% were in states won by Trump.

Allowing the enhanced subsidies to expire could also reshape the market.

Brooker said some people may drop coverage. Others will shift to plans with lower premiums but higher deductibles. One provision of Trump’s new tax law allows people enrolled in either “bronze” or “catastrophic”-level ACA plans, which are usually the cheapest, to qualify for health savings accounts, which allow people to set aside money, tax-free, to cover health care costs.

“Naturally, if rates do start going up the way we anticipate, there will be a migration to lower-cost options,” Brooker said.

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Now, another proposed twist in the rules could mean that, even though Missouri pays her to do that work, she might still have to prove to the state that she’s not unemployed.

The Kansas City, Missouri, resident has cared for her disabled son, Daniel, for all 31 years of his life. A rare genetic condition called Prader-Willi syndrome, in addition to autism, left him with an intellectual disability; a constant, excessive hunger; and an inability to speak. His needs left Gallagher, an elementary school teacher by training, with little opportunity to work outside her home.

As congressional Republicans slash in federal Medicaid spending, Gallagher is among the 18.5 million Americans who could be required to prove that they work enough to keep their health insurance.

A budget bill that passed the House and Senate would require 80 hours of work or community service a month for adults who are insured through the Affordable Care Act’s Medicaid expansion program, which has allowed states to extend Medicaid coverage to more adults with low incomes. Forty states, plus Washington, D.C., have expanded their programs, additions that now cover about 20 million Americans, including Gallagher.

She enrolled in the coverage in December 2023, after she could no longer afford her private insurance. Before her husband died of cancer in 2019, the couple paid for private insurance and supported themselves on the income he earned as a master watchmaker. After his death, Gallagher was left to earn a living and find insurance on her own. At 59, she’s too young to collect her husband’s Social Security survivor benefit.

The Medicaid program that pays for in-home care for Daniel and 8,000 other Missourians with disabilities allows family members to be compensated for caregiving, but only if they’re not the legal guardian of the person they care for. So, Gallagher went to court to give up her rights to make decisions for her son and transfer authority to her parents.

“I think it’s appalling that it’s required, but it was necessary,” she said. “There was no way I could work outside of taking care of Daniel.”

Republicans have touted Medicaid work requirements both as a way to reduce federal spending on the program and as a moral imperative for Americans.

“Go out there. Do entry-level jobs. Get into the workforce. Prove that you matter. Get agency into your own life,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said in a recent interview on Fox Business.

Democrats, meanwhile, have red tape that won’t meaningfully increase employment but will cause eligible people to lose their health insurance because of administrative hurdles.

Indeed, the of Americans enrolled in Medicaid expansion are already working, caregiving, attending school, or have a disability, according to an analysis by Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

And while the Congressional Budget Office estimates the work requirement included in the House bill would cause to lose their insurance, only of those people are unemployed because of lack of interest in working, according to the Urban Institute, a nonprofit research group. Recent history in states that have tried work requirements suggests technical and paperwork problems have caused a substantial portion of coverage losses.

Still, the provisions are generally popular among Republican lawmakers and the public. Sen. Josh Hawley (R-Mo.), who has cutting people off from Medicaid, has signaled support for adding work requirements.

And 68% of Americans favor the requirement described in the House bill, according to a conducted by Â鶹ŮÓÅ. But support for work requirements dropped as low as 35% when respondents learned that most Medicaid recipients already work and could lose their coverage because of paperwork requirements.

That’s what happened in Arkansas, where 18,000 people in 2018 after the state phased in a work requirement. Thousands more were on pace to lose coverage in 2019 before a , largely over concerns about coverage losses. In discussions with focus groups, Â鶹ŮÓÅ found that many Arkansas Medicaid participants did not fully understand the requirements, despite the state’s outreach efforts, and some people didn’t receive mailed notices. Others were confused because the work-reporting paperwork and separate forms to renew Medicaid coverage asked for similar information.

Many family caregivers would be exempt from the work requirements proposed in Congress, but Gallagher probably would not, since she had to relinquish guardianship of her son to be paid for the work. While the hours she already logs should be enough to satisfy the requirement, she’ll need to report them again — unless the state can identify her through its existing data. But Missouri has a history of procedural problems in the state agency that administers Medicaid.

In early 2022, for example, Missouri was taking more than 100 days on average to process applications for Medicaid expansion, a wait that prompted patients to put off needed care and was more than twice the processing time allowed by federal law.

And 79% of the more than 378,000 Missourians who lost Medicaid coverage when covid-era enrollment protections ended in 2023 did so because .

The next year, a federal judge ruled that Missourians were by the state, in part because insufficient staffing at call centers left eligible people without assistance.

“They’re historically understaffed,” Timothy McBride, a health economist at Washington University in St. Louis, said of the state agency that administers Medicaid and food assistance. “I think that’s really the underlying problem.”

McBride’s analysis of Missouri’s Medicaid recipients found that of the people enrolled in expansion in 2023 were unemployed for reasons other than caregiving, disability, attending school, or retirement. But many Missourians could lose their insurance if work requirements prompt disenrollment rates similar to Arkansas’ implementation, according to a study from the Center on Budget and Policy Priorities, a left-leaning think tank that analyzes government policies.

The estimate assumes many otherwise eligible people would still lose coverage as a result of falling through the cracks, McBride said.

Hawley, who backed the Senate bill, declined to comment for this article. The senator previously that “we can sort that out” when asked about eligible people inadvertently losing Medicaid because of work requirements.

Gallagher worries about her coverage, because she recently was diagnosed with Hashimoto’s disease, an autoimmune disorder that attacks the thyroid gland. She said she had to search for her Medicaid card to fill the prescription that followed, having barely used it in the year in a half she’s been covered.

She also worries about her son’s Medicaid. A nursing home is not a realistic option, considering his needs. His coverage doubles as Gallagher’s only source of income and also pays for other caregivers, when she can find them, who give her breaks to tend to her own health and to her aging parents.

But nearly all like those Daniel receives are optional programs that states are not required to include in their Medicaid programs. And the magnitude of the cuts being proposed have prompted fears that the optional programs could be chopped.

“It would destroy our lives,” Gallagher said. “The only income we would have would be Daniel’s Social Security.”

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President Donald Trump’s domestic policy legislation, the One Big Beautiful Bill Act that cleared the House in May and now moves to the Senate, could also be called Obamacare Repeal Lite, its critics say. In addition to causing millions of Americans to lose their coverage under Medicaid, the health program for low-income and disabled people, the measure includes the most substantial rollback of the ACA since Trump’s Republican allies that would have largely repealed President Barack Obama’s signature domestic accomplishment.

One difference today is that Republicans aren’t describing their legislation as a repeal of the ACA, after the 2017 effort cost them control of the House the following year. Instead, they say the bill would merely reduce “waste, fraud, and abuse” in Medicaid and other government health programs.

“In a way, this is their ACA repeal wish list without advertising it as Obamacare repeal,” said , an associate professor of political science at Marquette University in Milwaukee and co-author of the book “Obamacare Wars: Federalism, State Politics, and the Affordable Care Act.”

The GOP, Rocco said, learned eight years ago that the “headline of Obamacare repeal is really bad politics.”

Democrats have tried to frame Trump’s One Big Beautiful Bill Act as an assault on Americans’ health care, just as they did with the 2017 legislation.

“They are essentially repealing parts of the Affordable Care Act,” Rep. Frank Pallone Jr. (D-N.J.) said as the House debated the measure in May. “This bill will destroy the health care system of this country.”

of adults have a favorable view of the ACA, according to polling by Â鶹ŮÓÅ, a national health information nonprofit that includes Â鶹ŮÓÅ Health News.

In contrast, about half of people polled also say there are major problems with waste, fraud, and abuse in government health programs, including Medicaid,

“We are not cutting Medicaid,” House Speaker Mike Johnson said May 25 on CNN’s “State of the Union,” describing the bill’s changes as affecting only immigrants living in the U.S. without authorization and “able-bodied workers” whom he claimed are on Medicaid but don’t work.

The program is “intended for the most vulnerable populations of Americans, which is pregnant women and young single mothers, the disabled, the elderly,” he said. “They are protected in what we’re doing because we’re preserving the resources for those who need it most.”

The 2025 legislation wouldn’t cut as deeply into health programs as the failed 2017 bill, which would have led to about 32 million Americans losing insurance coverage, the Congressional Budget Office estimated at the time. By contrast, the One Big Beautiful Bill Act, with provisions that affect Medicaid and ACA enrollees, would leave 11 million more people without health insurance by 2034, according to the , released June 4.

That number rises to about 16 million when including the Trump administration’s proposed tightening of ACA marketplace eligibility and if Congress doesn’t extend premium subsidies for Obamacare plans that were enhanced during the pandemic to help more people buy insurance on government marketplaces, the CBO says. Without congressional action, the more generous subsidies will expire at the end of the year and rise sharply.

The increased financial assistance led to a record 24 million people enrolled in ACA marketplace plans this year, and health insurance experts predict a large reduction without the enhanced subsidies.

Loss of those enhanced subsidies, coupled with other changes set in the House bill, will mean “the ACA will still be there, but it will be devastating for the program,” said , founding director of the Center for Health Policy and the Law at Georgetown University.   

Republicans argue that ACA subsidies are a separate issue from the One Big Beautiful Bill Act and accuse Democrats of conflating them.

The House-passed bill also makes a of ACA changes, including shortening by a month the annual open enrollment period and eliminating policies from Joe Biden’s presidency that allowed many low-income people to sign up year-round.

New paperwork hurdles the House bill creates are also expected to result in people dropping or losing ACA coverage, according to the CBO.

For example, the bill would end most automatic reenrollment, which was used by this year. Instead, most ACA enrollees would need to provide updated information, including on income and immigration status, to the federal and state ACA marketplaces every year, starting in August, well before open enrollment.

Studies show that additional administrative hurdles lead to people dropping coverage, said , a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

“Not only do people drop out of the process, but it tends to be healthier, younger, lower-income folks who drop out,” she said. “That’s dumb because they go uninsured. Also, it is bad for the insurance market.”

Supporters of the provision say it’s necessary to combat fraudulent enrollment by ensuring that ACA beneficiaries still want coverage every year or that they are not being enrolled without their permission by rogue sales agents. Most of the Medicaid coverage reductions in the bill, , are due to new work requirements and directives for the 21 million adults added to the program since 2014 under an expansion authorized by the ACA.

One new requirement is that those beneficiaries prove their eligibility every six months, instead of once a year, the norm in most states.

That would add costs for states and probably lead to people who are still eligible falling off Medicaid, said Oregon Medicaid Director Emma Sandoe. Oregon has one of the most liberal continuous eligibility policies, allowing anyone age 6 or older to stay on for up to two years without reapplying.

Such policies help ensure people don’t fall off for paperwork reasons and reduce administrative burden for the state, Sandoe said. Requiring more frequent eligibility checks would “limit the ability of folks to get care and receive health services, and that is our primary goal,” Sandoe said.

The 2017 repeal effort was aimed at fulfilling Trump’s promises from his first presidential campaign. That’s not the case now. The health policy provisions of the House bill instead would help to offset the cost of extending about $4 trillion in tax cuts that skew toward wealthier Americans.

The Medicaid changes in the bill would reduce federal spending on the program by about $700 billion over 10 years. CBO has not yet issued an estimate of how much the ACA provisions would save.

a health economist at Washington University in St. Louis, said Republican efforts to make it harder for what they term “able-bodied” adults to get Medicaid is code for scaling back Obamacare.

The ACA’s Medicaid expansion has been adopted by 40 states and Washington, D.C. The House bill’s work requirement and added eligibility checks are intended to drive off Medicaid enrollees who Republicans believe never should have been on the program, McBride said. Congress approved the ACA in 2010 with no Republican votes.

Most adult Medicaid enrollees under 65 are already working, studies show. Imposing requirements that people prove they’re working, or that they’re exempt from having to work, to stay on Medicaid will lead to some people losing coverage simply because they don’t fill out paperwork, researchers say.

Manatt Health estimates that about 30% of people added to Medicaid through the ACA expansion would lose coverage, or about 7 million people, said Jocelyn Guyer, senior managing director of the consulting firm.

The bill also would make it harder for people enrolled under Medicaid expansions to get care, because it requires states to charge for some specialist services for those with incomes above which is $15,650 for an individual in 2025.

Today, copayments are rare in Medicaid, and when states charge them, they’re typically nominal, usually under $10. Studies show cost sharing in Medicaid among beneficiaries.

, a senior fellow with the conservative Manhattan Institute, acknowledged that some people will lose coverage but rejected the notion that the GOP bill amounts to a full-on assault on the ACA.

He questioned the coverage reductions forecast by the CBO, saying the agency often struggles to accurately predict how states will react to changes in law. He said that some states may make it easy for enrollees to satisfy new work requirements, reducing coverage losses.

By comparison, Pope said, the ACA repeal effort from Trump’s first term a decade ago would have ended the entire Medicaid expansion. “This bill does nothing to stop the top features of Obamacare,” Pope said.

But McBride said that while the number of people losing health insurance under the GOP bill is predicted to be less than the 2017 estimates, it would still eliminate about half the ACA’s coverage gains, which brought the U.S. uninsured rate to historical lows. “It would take us backwards,” he said.

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About two-thirds of Republican-leaning parents are unaware of an uptick in measles cases this year while about two-thirds of Democratic ones knew about it, according to a .

Republicans are far more skeptical of vaccines and twice as likely (1 in 5) as Democrats (1 in 10) to believe the measles shot is worse than the disease, according to the survey of 1,380 U.S. adults.

Some 35% of Republicans answering the survey, which was conducted April 8-15 online and by telephone, said the discredited theory linking the measles, mumps, and rubella vaccine to autism was definitely or probably true — compared with just 10% of Democrats.

The trends are roughly the same as Â鶹ŮÓÅ reported in a June 2023 survey. But in the new poll, 3 in 10 parents erroneously believed that vitamin A can prevent measles infections, a theory Health and Human Services Secretary Robert F. Kennedy Jr. has brought into play since taking office during the measles outbreak.

About 900 cases have been reported in 27 U.S. states, mostly in a West Texas-centered outbreak.

“The most alarming thing about the survey is that we’re seeing an uptick in the share of people who have heard these claims,” said co-author Ashley Kirzinger, associate director of Â鶹ŮÓÅ’s Public Opinion and Survey Research Program. Â鶹ŮÓÅ is a health information nonprofit that includes Â鶹ŮÓÅ Health News.

“It’s not that more people are believing the autism theory, but more and more people are hearing about it,” Kirzinger said. Since doubts about vaccine safety directly reduce parents’ vaccination of their children, “that shows how important it is for actual information to be part of the media landscape,” she said.

“This is what one would expect when people are confused by conflicting messages coming from people in positions of authority,” said Kelly Moore, president and CEO of Immunize.org, a vaccination advocacy group.

Numerous scientific studies have established no link between any vaccine and autism. But Kennedy has ordered HHS to undertake an investigation of possible environmental contributors to autism, promising to have “” behind an increase in the incidence of the condition by September.

The deepening Republican skepticism toward vaccines makes it hard for accurate information to break through in many parts of the nation, said Rekha Lakshmanan, chief strategy officer at The Immunization Partnership, in Houston.

Lakshmanan on April 23 was to present a paper on countering anti-vaccine activism to the World Vaccine Congress in Washington. It was based on a survey that found that in the Texas, Louisiana, Arkansas, and Oklahoma state assemblies, lawmakers with medical professions were among those least likely to support public health measures.

“There is a political layer that influences these lawmakers,” she said. When lawmakers invite vaccine opponents to testify at legislative hearings, for example, it feeds a deluge of misinformation that is difficult to counter, she said.

Eric Ball, a pediatrician in Ladera Ranch, California, which was hit by a 2014-15 measles outbreak that started in Disneyland, said fear of measles and tighter California state restrictions on vaccine exemptions had staved off new infections in his Orange County community.

“The biggest downside of measles vaccines is that they work really well. Everyone gets vaccinated, no one gets measles, everyone forgets about measles,” he said. “But when it comes back, they realize there are kids getting really sick and potentially dying in my community, and everyone says, ‘Holy crap; we better vaccinate!’”

Ball treated three very sick children with measles in 2015. Afterward his practice stopped seeing unvaccinated patients. “We had had babies exposed in our waiting room,” he said. “We had disease spreading in our office, which was not cool.”

Although two otherwise healthy young girls died of measles during the Texas outbreak, “people still aren’t scared of the disease,” said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, which has seen a few cases.

But the deaths “have created more angst, based on the number of calls I’m getting from parents trying to vaccinate their 4-month-old and 6-month-old babies,” Offit said. Children generally get their first measles shot at age 1, because it tends not to produce full immunity if given at a younger age.

Â鶹ŮÓÅ Health News’ Jackie Fortiér contributed to this report.

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Here are four considerations for lawmakers on the Senate Finance and Senate Health, Education, Labor and Pensions committees, which will host Kennedy for questioning on Wednesday and Thursday, respectively:

1) Kennedy’s unconventional health claims.

, Kennedy has advocated for health-related ideas that are scientifically disproven or controversial. He created and was paid hundreds of thousands of dollars by Children’s Health Defense, a group that champions the that vaccines cause autism and other chronic diseases and has sued to take vaccines off the market. Kennedy has said covid vaccines are the , antidepressants mass shootings, environmental contaminants may , and HIV is of AIDS. He also pushes the use of products that regulators consider dangerous, such as raw milk, and for broader use of some medicines, such as ivermectin and hydroxychloroquine, to treat conditions without FDA approval. He says public health agencies oppose their use only because of regulatory capture by big drug and food interests.

“He believes you can avoid disease if you have a healthy immune system. He sees vaccines and antibiotics as toxins,” said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia. Top Trump health nominees — Kennedy, Marty Makary for FDA commissioner, Jay Bhattacharya for National Institutes of Health director, and former U.S. Rep. Dave Weldon for Centers for Disease Control and Prevention director — are generally disdainful of the agencies they’ll be leading, Offit said.

“They think they are going to go into office, pull back the curtain, find all this bad stuff, and reveal it to the American public,” he said.

During a measles epidemic in 2019 and 2020 that , mostly children, in Samoa, Kennedy, as chairman of Children’s Health Defense, warned the country’s prime minister against measles vaccination. This behavior alone “is disqualifying” for an HHS nominee, said Georges Benjamin, executive director of the American Public Health Association.

Equally problematic, in Benjamin’s view, was Kennedy’s legal effort in 2021 to get the covid vaccine pulled from the market. “He can’t say he’s not anti-vax,” Benjamin said. “He wasn’t following the evidence.”

A Kennedy spokesperson did not respond to a request for comment.

2) Kennedy’s chances appear good, despite opposition.

Kennedy’s nomination has emerged in a moment when Trump is on a roll and mistrust of public health and medical authority in the wake of the pandemic has created an opening for people with unorthodox views of science to seize the reins of the country’s health system.

After former Fox News personality Pete Hegseth was confirmed as Defense secretary last week despite his controversial qualifications for the job and stark warnings from former top military brass, many Washington observers think RFK Jr. is going to be hard to defeat. In a meeting on the Hill with Democratic senators and their aides last week, Offit said, “the feeling was that he would likely be confirmed.”

that Republican senators line up behind his nominees and has so far succeeded. It’s thought that Sens. Lisa Murkowski of Alaska and Susan Collins of Maine could oppose Kennedy, based on their opposition to Hegseth. Sen. Mitch McConnell (R-Ky.), the other Hegseth “nay” vote, is a polio survivor who has not spoken publicly about Kennedy but said in December that opposing “proven cures” was dangerous. Other senators whose Kennedy votes are said to be in question include Sen. Bill Cassidy (R-La.), the HELP Committee chair, a physician who gave a lukewarm response after meeting Kennedy.

Others have reported that Sens. (D-N.J.), who shares Kennedy’s concern with the spread of obesity and chronic illness, and (D-R.I.), who attended law school with Kennedy, might vote for him. Neither senator’s office responded to a request for comment. Advancing American Freedom, a conservative advocacy group founded by former Vice President Mike Pence, has with a major ad buy.

3) The hearings are going to be heated.

Democratic senators are coming with plenty of ammunition. Sen. Elizabeth Warren (D-Mass.) sent Kennedy a on everything from his anti-vaccine statements and actions to his waffling positions on abortion to his stances on Medicare, drug prices, and the cause of AIDS.

While public health and medical groups did not coordinate with Pence’s conservative organization, questions about Kennedy’s earlier stance in support of abortion rights could raise hackles on the GOP side of the aisle. Although his group is far from Pence on reproductive rights, Benjamin said, “if it helps derail him, I hope some senators are listening to Pence. Any shelter in a storm.”

“The hearings are going to be very difficult for him because he’s told a web of untruths as he’s marched across the offices,” said Leslie Dach, executive chair of Protect Our Care, a Democratic-aligned advocacy group.

Public opinion reflects leeriness of Kennedy on health, though not excessively. In a poll released Tuesday by Â鶹ŮÓÅ, 43% of respondents said they trusted him to make the right health recommendations. About 81% of Republicans in the poll said they trusted Kennedy — almost as many as trust their own doctor.

4) What happens if Kennedy takes office.

At the NIH, FDA, and other federal health agencies, nervous scientists speak of early retirement or jumping to industry should Kennedy and his agency heads take office.

The pharmaceutical industry has kept quiet on the nomination, as has the American Medical Association. Many patient advocacy groups are worried, but wary of creating friction with an administration they can’t ignore or defeat.

Kennedy’s comments on AIDS — suggesting that gay men’s use of stimulants, rather than the HIV virus, were its cause — are troubling to Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. But “I don’t know if he’s going to get confirmed or not,” he said. “If he does, we look forward to working with him and educating him.”

At the J.P. Morgan Healthcare conference earlier this month, Emma Walmsley, CEO of GSK, a leading vaccine maker, said she’d “wait and see what the facts are” before predicting what Kennedy would do. Vaccines, she noted, are “not our biggest business.”

GSK is one of a handful of vaccine makers remaining on the U.S. market. That number could shrink further if the Trump administration and Congress undo a 1986 law that provided legal protection for vaccine makers — as Kennedy has advocated.

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