Tag Archives: Medicaid

Shutdown in Washington: Healthcare Issues at the Core of the Debate

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment

http://www.rockinst.org

In a recent blog post, Looming Government Shutdown? A Brief Overview of Expiring Federal Authorizations, the Rockefeller Institute of Government detailed the health care policies and programs requiring an extension and, in some cases, funding by Congress. For over two weeks now, failure to reach agreement on a Continuing Resolution (CR) to keep the federal government fully funded has resulted in a temporary federal shutdown.

The debate is both highly nuanced and politically charged. It involves multiple healthcare issues. The House passed a CR (sometimes also referred to as an extender) that would largely continue current funding levels through November 21, 2025, but with some new spending items, such as additional funding for congressional member security. Thus far, the Senate majority has not had the votes to pass the extender.

Under Senate rules, 60 votes are required to overcome a filibuster. This necessitates at least seven Democratic senators to vote with the Republican majority for passage. Only three Democratic senators and one Independent have voted in favor of the House-passed extender to date, and one Republican did not vote with the majority. This leaves the current vote count at 56 out of the necessary 60 votes.

The Democrats are seeking an amendment to the Republican supported CR, which would fund the government through October 31, 2025. At the core of the current dispute, the Democratic minority is seeking, among other things, in its proposed amendments: (1) restorations of the health care cuts in the recently passed HR1—also known as the One Big Beautiful Bill Act (OBBBA), and (2) permanent extension of federal funding not included in HR1 for enhanced subsidies—known as advance premium tax credits (APTC). APTCs provide additional federal funding to lower the cost of health insurance coverage purchased through the Affordable Care Act (ACA) marketplaces. These enhanced APTC subsidies were initially authorized during the COVID pandemic and are set to expire at the end of 2025, unless extended. In essence, the disagreement is over the health care cuts HR1 made, which were followed by more restrictive regulations governing the purchase of health insurance coverage, and whether Congress will continue COVID-era enhanced subsidies.

Additionally, while not included in the broader media coverage, the Rockefeller Institute has previously highlighted October 1, 2025, as the scheduled implementation date for reductions to Disproportionate Share Hospital (DSH) payments. DSH provides federal funds to hospitals that serve a high number of low-income and uninsured patients to help cover their uncompensated care costs.1 Language delaying the cuts to DSH is in both the Republicans’ CR as well as the Democrats’ proposal.

Restoration of HR1 Cuts

Prior work by the Institute, as well as other commentators, has detailed the funding cuts and other changes included in HR1 and through federal regulation, and their adverse impacts on New York’s $300 billion healthcare economy.

The Democratic minority in the Senate is seeking restorations for all of the health provisions changed in HR1. Of the Democrats’ proposed restorations, three specific areas that have been the subject of the Republican majority’s criticism include proposals relating to the financing of healthcare for certain non-citizens (both lawfully residing and illegally residing). The proposals or restorations include: (1) permitting particular lawfully residing immigrants (persons residing under color of law, or “PRUCOL”) to purchase health insurance on the official ACA marketplace, who were excluded in HR1; (2) reversing the narrowed definition of PRUCOL in HR1; and (3) restoring the federal matching share of emergency Medicaid funding which was reduced in HR1.

These issues have been subject to oversimplification in public and political discourse. Prior Rockefeller Institute of Government writings have clearly detailed these programs and who is or is not eligible. At the core of the issue, with limited exception relating to the percentage of federal funding for emergency Medicaid,2 federal funds have always been prohibited from funding coverage for those who are not lawfully residing in New York or other states. However, HR 1 also significantly reduced federal funding for both emergency care, which is provided to undocumented persons during a life-threatening emergency, and for lawfully residing residents, like refugees and asylees, that was previously authorized.3

New York estimates the changes to the definition and eligibility for the tax credits in HR1, and the enhanced subsidy expiration that was not extended in HR1, would result in a loss of over $7.5 billion in funding to New York’s healthcare economy, beginning January 1, 2026. In particular, the change in HR1 removing certain immigrants from eligibility for APTC reduces available federal funding to the State. As a result of these changes, on September 10, 2025, New York made a request to terminate the Section 1332 State Innovation Waiver and return to the Basic Health Program, risking coverage for approximately 450,000 New Yorkers with incomes between 200 and 250 percent of the poverty limit who, as a result of the loss of funding will have to purchase coverage on the exchange, obtain coverage through their employer or become uninsured. The comment period for the notice concluded on October 10, 2025, and anticipated submission to CMS was scheduled for October 15, 2025.

Some portion of the restoration of HR1 cuts that are being proposed may, however, go to undocumented immigrants with respect to emergency Medicaid funding. Medicaid pays a share of the financing of emergency Medicaid services for persons with life-threatening or organ-threatening conditions—this was the case both before and after HR1. HR1 continues to fund emergency Medicaid, but reduces the federal share from 90 percent to 50 percent for certain adults.

According to New York State Department of Health data provided to the Empire Center for Public Policy, a think tank, as of March 2024, there are 480,000 noncitizens enrolled in the emergency Medicaid program. These are largely undocumented immigrants who are otherwise not eligible for Medicaid or the Essential Plan as a qualified alien, PRUCOL, or through any other program. Absent emergency Medicaid federal funding, however, hospitals would still be required to provide care in emergent situations under the Federal Emergency Medical Treatment and Labor Act (EMTALA ) without federal money to reimburse those hospitals for that care. EMTALA was a bipartisan bill that was signed by President Regan back in 1986. Among other things, EMTALA protects everyone—primarily US citizens—who need immediate emergency care by requiring hospitals to treat patients whether they have proof of identity or insurance, or not.

The debate in Washington over restoring cuts passed in HR1 may not be resolved in a CR. Despite the potential impacts on federal funding to New York associated with the currently passed CR in the House and, therein, maintaining HR1’s changes and funding cuts, there are other important elements that, if excluded from an agreement, would add to the impact of HR1 reductions.

This post summarizes two important issues that are of significant financial impact to New York, which could be important elements of a potential bipartisan compromise solution.

Extending Enhanced Advance Premium Tax Credits and Disproportionate Share Hospital Funding

In addition to restoration of the health care cuts in HR1, a second key issue in the current federal shutdown relates to programs with significant financial impact to New York that were not addressed in HR1: continued funding for Enhanced Advance Premium Tax Credits (APTC), as well as extension of the Disproportionate Share Hospital (DSH) funding at current levels. A permanent extension of the enhanced APTCs was included in the Democrat minority CR, and both parties included an extension of current DSH funding in their respective proposals.

Enhanced APTC

Enhanced APTC federal funds are used to lower health insurance premium costs for qualified health plan (QHP) coverage purchased through ACA health marketplaces. The extension of enhanced APTC, which was not addressed in HR1, relates to enhanced subsidies for purchasing qualified health plan (QHP) coverage. Existing subsidies for those not enrolled in Medicaid, Medicare, or other coverage that provide financial assistance beyond what was authorized under the Affordable Care Act (ACA) are set to expire on December 31, 2025.

The enhanced APTC subsidies were initially authorized during COVID-19 in the American Rescue Plan Act (ARPA) and extended in the Inflation Reduction Act.4 Not only were the enhanced subsidies for purchasing health insurance coverage increased (for those who were already receiving a subsidy) through advance premium tax credits, but eligibility for subsidies was expanded to include those above 400 percent of the federal poverty limit ($62,600 for an individual and $128,600 for a family of four in 2025).

The extension of the enhanced APTC was neither included in HR1, nor was it included in the Republican’s continuing resolution. As a result, it has been less widely publicized component of the current healthcare debate in Washington than the proposals to restore reductions in funding for non-citizen care, in the Democrat version of the CR.

At present, it remains unclear if the COVID-era enhanced premium tax credits will be renewed by Congress. The CR proposed by the Congressional majority only provides continued funding of existing programs through November 21st and would not solve the subsidy cliff (a sudden and steep increase in premiums for those purchasing coverage in the individual or small group market) before open enrollment begins on November 1st. Despite the fact that this issue remains open in the federal funding debate, there has been strong public support as of late for extending enhanced APTC. Of those polled by the Kaiser Family Foundation between September 23 and September 29, 2025, 78 percent of respondents indicated Congress should extend the enhanced tax credits (92 percent of Democrats, 82 percent of independents and 59 percent of Republicans).

Moreover, in mid-late September, Republican Senator Lisa Murkowski (AK), who voted against the CR, proposed a two-year extension in efforts to reach agreement on the potential shutdown, and news outlets reported5 that Republican senators were working on legislation that would extend the subsidies. At present, it appears Senator Murkowski is the only sponsor of her bill (S. 2824), which would extend the subsidies for two years. There is also currently proposed legislation, the Bipartisan Premium Tax Credit Extension Act (H.R. 5145), which would extend the enhanced subsidies for one year, through December 31, 2026. As of October 9th, 2025, there are 27 bipartisan House co-sponsors, including three members of the New York Congressional Delegation sponsoring the bill: Representatives Suozzi (D, NY-3), Lawler (R, NY-17), LaLota (R, NY-1).

Absent legislative action, it is estimated by the Kaiser Foundation that the cost to purchase health insurance in the individual market could increase by over 75 percent nationally due to the subsidy expiration.

While New York and other states would be impacted, the enhanced subsidies have the greatest direct impact in the 10 remaining non-Medicaid expansion states: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.6 These states account for 79 house majority votes (out of 106 associated with the 10 states in total).

Moreover, there are particular and significant portions of the population within and outside of these states that would be greatly impacted. According to Kaiser, nationally, “more than a quarter of farmers, ranchers, and agricultural managers had individual market health insurance coverage (the vast majority of which is purchased with a tax credit through the ACA Marketplaces). About half (48%) of working-age adults with individual market coverage are either employed by a small business with fewer than 25 workers, self-employed entrepreneurs, or small business owners. Middle-income people who would lose tax credits altogether are disproportionately early and pre-retirees, small business owners, and rural residents.

And while the ACA Marketplaces have doubled in size nationally since these enhanced tax credits became available, more than half of that growth is concentrated in Texas, Florida, Georgia, and North Carolina.”7

DSH Funding

Medicaid Disproportionate Share Hospital (DSH) payments are federal payments to hospitals that serve a high number of low-income and uninsured patients to help cover their uncompensated care costs. These payments are a critical form of financial assistance for “safety-net” hospitals, helping them remain financially stable and continue providing essential services to vulnerable populations. Federal law requires states to make these payments to qualifying hospitals, but there are overall and state-specific limits on the total amount of funding available.

Funding for the DSH program was set to expire on or about October 1, 2025. Extension of the DSH program was not included in HR1. As discussed below, the impact on “safety-net” hospitals in New York is significant.

Impact on New York

Expiration of Enhanced APTC

In 2022, the last time the Enhanced APTC subsidies were set to expire, New York State estimated that their expiration would increase premium costs for qualified health plan (QHP) enrollees by 58 percent and reduce funding to the Essential Plan by $600–$700 million.8 New York recently estimated the impact at 38 percent following passage of the House bill, which did not include the extension. According to NYSOH, the subsidy benefits nearly 140,000 New Yorkers and reduces coverage costs by $1,368 per person annually (previously $1,453 in 2022), which equates to over $200 million in federal funding that would be diverted from New Yorkers currently purchasing coverage on the exchange.

Additionally, New York has experienced higher-than-average premium increases in recent years, so when combined with reductions to subsidies, this may make it more difficult for people to afford to buy coverage and could further exacerbate the shrinking New York individual and small group health insurance markets. Premium increases in New York exceed national trends.9 Part of this in New York (as opposed to other states) is due to the use of various health-related taxes, which were detailed in How Health Care Policy in Washington Could Affect New York.

Rate increases for individual, small group, and large group health insurance for the 2026 plan year were reviewed and approved, with changes, by the Department of Financial Services (DFS) in August 2025. According to DFS, individual plans will increase by an average of 7.1 percent, while small group plans will increase by an average of 13 percent, both of which are significantly less than was requested by the insurers.

New York operates a Basic Health Program (BHP) option in the ACA, known as the Essential Plan (EP). The EP is a public health insurance program for New Yorkers with incomes above the maximum Medicaid eligibility (138 percent of the federal poverty limit) and below 200 percent of the poverty limit, or with the 1332 Waiver below 250 percent of the poverty limit (FPL). The BHP provision in the ACA only allows eligibility up to 200 percent FPL. Using a provision in section 1332 of the ACA that allows for federal regulators to make certain adjustments (or waivers), New York increased EP eligibility to 250 percent FPL. However, as a result of funding reductions enacted in the HR1, New York is currently seeking to reverse its waiver expansion, bringing the future maximum eligibility to 200 percent of the FPL.

Using January 2025 enrollment data, absent other changes, the estimated lost funding to the Essential Plan would jump from $1 billion to $1.2 billion. Changes enacted in HR1 (which the Democrats are currently seeking to reverse) reduce the value of the enhanced subsidies to New York by approximately one-third, as certain legally residing non-citizens are no longer eligible for any subsidies pursuant to the federal changes.10

Enhanced Premium Tax Credit—Impact of Expiration in New York 11

An extension or lack thereof of the subsidy has important implications for healthcare financing and access to coverage in the State of New York. At present, New York stands to lose $1.2 billion to $1.4 billion associated with the loss of the enhanced subsidies, including $1.0 billion to $1.2 billion currently used to provide low-cost coverage to 1.6 million persons with incomes between 138 and 250 percent of the poverty limit and nearly $200 million for 140,000 individuals purchasing coverage on New York State of Health (NYSOH).

Timing for Consumers

November 1, 2025, marks the beginning of the open enrollment period for purchasing coverage on a state or federally operated exchange for the 2026 plan year. Consumers can begin renewing plans beginning November 16, 2025, for those purchasing a qualified health plan on New York State of Health (NYSOH), with a December 15, 2025, deadline to enroll in coverage that begins on January 1, 2026.

In addition to NYSOH’s website and app, New York health insurance notices for the 2026 plan year are to be sent out by November 1, 2025, detailing premium information, including any applicable APTC. The notices will also list the income used for the automatic renewal determination in a section titled “How We Made Our Decision.” For enrollees who do not agree with the renewal determination, they can update their application on NYSOH between November 16, 2025, and December 15, 2025, to avoid a gap in coverage starting January 1, 2026.

Those rate notices are already being loaded into the plan systems and NYSOH online, as it takes some weeks to get the rate notices set and out to enrollees. If Congress does not act imminently to reauthorize the expanded APTC, consumers will receive notices that reflect 2026 premiums without the expanded APTC.

Indeed, NYSOH has already put online, as of October 1, 2025, the ‘Compare Plans’ and ‘Estimate Costs’ tool on the website, which allows consumers to look at plan options and evaluate costs. And, for consumers using the tool now, it already reflects that the Expanded APTCs will not be available for 2026.

Potential Enhanced APTC Compromise

There are three basic options available to Congress with some variation on duration with regard to the enhanced APTCs. Congress could:

  1. Allow the enhanced APTCs to expire. If no compromise is reached, Congress could simply do nothing and funding for the Enhanced APTCs will stop at the end of 2025.
  2. Extend the existing enhanced APTCs. The parties could compromise and extend the enhanced APTCs either permanently or temporarily to some date certain. As noted above, a bipartisan bill (H.R. 4541) would extend the enhanced APTCs for one year, and Senator Murkowski carries a bill in the Senate (S. 2824) that would extend the subsidies for two years. The Senate Democratic minority CR would extend the existing subsidies permanently.
  3. Modify the eligibility criteria for enhanced APTCs. Currently, eligibility has no income limit as such, but the enhanced APTC subsidies ensure that no one spends more than 8.5 percent of income for the benchmark silver plan. Congress could make changes that include: (1) modifying the eligibility criteria to the level under the ACA to 400% of the federal poverty level (FPL); (2) adjusting the limit of the percent of income for the benchmark silver plan above (or below) 8.5 percent; or (3) some other rules that limit or expand income eligibility.

Congress could also explore options that modify the maximum amount a household would be required to contribute towards the cost of coverage (currently 8.5% for households above 400 percent of FPL) or limit the application of the marketplace coverage rule, which was detailed in a prior Rockefeller Institute of Government report.

Expiration of Disproportionate Share Hospital (DSH) Funding

Additionally, scheduled reductions to DSH funding, that absent a change to New York State law, would primarily affect the availability of DSH funding for New York City, which were delayed from starting in October 2025 to October 2026 through 2028 in the initial House Reconciliation bill, but not included in HR1, are effective October 1, 2025, absent a federal extension. The DSH reduction has been delayed by Congress more than a dozen times since enactment through the ACA.12

Under current law, the availability of $2.4 billion federal DSH funding to New York, or 15 percent of federal funding for DSH ($16 billion), would be reduced. DSH funding is matched by the state or locality (through an intergovernmental transfer), making New York’s total DSH program over $4.7 billion as of federal fiscal year 2025. The Medicaid and CHIP Payment and Access Commission (MACPAC) estimates New York State’s total DSH program, including federal and non-federal shares, would be reduced by $2.8 billion, which translates to a loss of $1.4 billion in federal DSH funding (or a nearly 59 percent reduction).

On September 23, 2019, immediately preceding the last government shutdown, CMS issued a final rule, finalizing the methodology to calculate the scheduled reductions to DHS funding, as initially enacted in the ACA, during the 2020 to 2025 period. It does not appear that the Trump administration has issued guidance related to implementation in 2025; however, the regulations track with the statute, meaning the Trump administration could implement the DSH reductions required under the ACA, absent agreement on a delay.

Like an extension of the enhanced subsidies for the APTCs, an extension (meaning a delay) of the DSH cuts is an important element for New York to avoid further significant loss of federal funding (in addition to the loss of funding as a result of HR1 and the potential expiration of the enhanced subsidies).

CONCLUSION

Multiple healthcare issues are at play in the Federal government shutdown. Democrats want to restore cuts and other actions made in HR1 in an effort to mitigate the impact on residents and the healthcare delivery system, including the State’s financial plan, while Republicans are not revisiting actions taken in HR1. Among others, requested cuts to be restored in HR1 include making certain legally residing non-citizens ineligible for federal funding to purchase comprehensive coverage on health insurance marketplaces, narrowing the definition of legally residing non-citizen for purposes of public program eligibility, and reducing the match rate for emergency Medicaid.

Two additional important issues are the impending expiration of enhanced subsidies for purchasing coverage on an official ACA marketplace and the impending implementation date for previously scheduled disproportionate share hospital (DSH) reductions. As referenced above, polling suggests that the extension of the subsidy has broad public support, and there is a bipartisan bill in Congress providing an extension. In the immediate days following the shutdown, positive polling around extending the enhanced APTC suggested there was a possibility of ending the shutdown with bipartisan support. While many states benefit from these subsidies, New Yorkers, more specifically, benefit from these subsidies on the exchange and in the Essential Plan, due to the State’s adoption of the Basic Health Program option for those with income slightly above Medicaid levels. While there is some coverage and indications of support regarding the enhanced APTC subsidies, the potential for the DSH cuts to be implemented is not in the mainstream media coverage.

Moreover, with regard to the enhanced APTC subsidies, we now see that the narrative from the Republican congressional majority is shifting,13 suggesting that the enhanced subsidies might not be part of resolving the current debate playing out in Washington.

Nevertheless, compromise is still possible, particularly in light of the disproportionate impact the expiration of the enhanced APTC will have on Republican-led states and the broad impact of the scheduled DSH reductions. One potential path to ending the shutdown where both sides could arguably claim victory would be to drop the demand for restoration of the health care cuts in HR1 in exchange for extending the enhanced APTC and again delaying the DSH cuts. While this potential “victory” would be a benefit to New York and reopen the federal government, that does not mean that the restoration of cuts enacted in HR1 would not also be important to New York in future negotiations.

It’s impossible to predict exactly where things are headed right now, but the Rockefeller Institute of Government continues to monitor developments in Washington, continuing past efforts to detail who and what is at stake in the current debates. This post is preceded by a series of healthcare reports, blogs, and podcasts by our health team, which include more information on the programs discussed in this post and related topics. More information can be found in these past works in the health series, which is available here.

Government shutdown puts hospital funding in peril

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
https://www.axios.com/2025/10/02/government-shutdown-hospital-funding-medicaid?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Hospitals in rural and underserved areas could lose out on billions of dollars in federal funding if the government shutdown drags on.

Why it matters: 

Many hospitals already run on tight margins and are bracing for fallout from Medicaid cuts and other changes in the One Big Beautiful Bill Act.

The big picture: 

The immediate concern is health policies that expired when government funding lapsed at midnight Tuesday. Health providers and their lobbyists expect Congress will make providers whole in an eventual funding deal and reimburse claims made during the shutdown.

  • But that’s not a given. And uncertainty about how long the shutdown will go on is leaving some of the most financially vulnerable hospitals in limbo.
  • “There’s just that underlying fear of, oh my gosh, what if they can’t come together on any agreement to open the government again, and we all get looped into it,” said Kelly Lavin Delmore, health policy adviser and chair of government relations at Hooper Lundy Bookman.

State of play: 

Safety-net hospitals face an $8 billion cut to Medicaid add-on payments in the absence of a government funding package.

  • The cuts to so-called disproportionate share hospital payments originate from the Affordable Care Act.
  • Congress has postponed the pay reductions more than a dozen times, but the most recent delay expired on Tuesday and Congress hasn’t signaled if or when it will step in.

The add-on payments are made quarterly, so hospitals may not feel immediate effects, even if Congress doesn’t further delay the cuts, according to the American Hospital Association. But state Medicaid agencies could let the cuts take place if they think lawmakers’ standoff will continue indeterminately, per AHA.

  • The uncertainty “really impacts that predictability and reliability as it relates to funding,” said Leonard Marquez, senior director of government relations and legislative advocacy at the Association of American Medical Colleges.
  • If the cuts do take effect, it would significantly hamper hospitals’ ability to care for their communities, Beth Feldpush, senior vice president of advocacy and policy at America’s Essential Hospitals, told Axios in a statement.

Additionally, two long-running programs that give pay bumps to rural hospitals expired on Wednesday.

  • One program adjusts Medicare payment upward for rural hospitals that discharge relatively few patients.
  • The other gives increased reimbursement rates to rural hospitals that have at least 60% of patients on Medicare.
  • They were designed to keep care available in communities that might otherwise not be able to support a hospital.
  • Both programs have expired in the past, only to be brought back to life with claims paid retroactively.

Zoom out: 

Hospital industry groups have also been urging Congress to extend enhanced Affordable Care Act tax credits, which have become a flashpoint in the shutdown fight. Democrat lawmakers have so far refused to pass GOP-led funding proposals that don’t include a full extension of the subsidies.

What they’re saying: 

AHA is urging Congress to find a bipartisan solution and reopen the government, a spokesperson told Axios.

  • “Patient care doesn’t go away with the loss of coverage and the loss of funding,” said Lisa Smith, vice president of advocacy and public policy for the Catholic Health Association.
  • “I just don’t know how long that’s going to be sustainable for our facilities that are really already operating on the margins.”

Medicaid overhaul shifts tough choices to states

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
https://www.axios.com/2025/09/19/medicaid-overhaul-states-tough-choices?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Republicans’ sweeping Medicaid overhaul has left a lot of the heavy lifting to governors and state health officials as the program launches the biggest package of changes in its 60-year history.

Why it matters: 

States working with hospitals, clinics and other providers will have to do more with less as they face about $1 trillion in program cuts and the likelihood of 10 million or more newly uninsured people from new work rules and other changes.

  • While the GOP views Medicaid as a waste-riddled program that’s due for a shakeup, the cuts will force painful tradeoffs at the local level as health systems also struggle with inflation, higher labor costs and rising medical costs.
  • “Congress left the dirty work to be done by the governors and state legislators, and that work will start very soon,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

State of play: 

Medicaid typically accounts for about 30% of a state’s budget each year. Spending goes up during tough economic times, and states are required to cover a set of mandatory benefits.

  • The fallout from the cuts will vary by state based on their reliance on certain funding mechanisms, like taxes on health care providers, and whether they’ve expanded Medicaid coverage under the Affordable Care Act.
  • The new work requirements only apply to people in the expansion group.

The biggest changes from the law will arrive in 2027. But states have already started planning for how they’ll implement work requirements, decide who’s eligible more frequently and cope with new restrictions on how they draw down federal funds.

  • They’ll also be competing for $50 billion in rural health funding that Congress added to the law — a sum that’s been widely criticized as inadequate.
  • “We are working day and night ever since this bill was passed,” New York’s Medicaid director, Amir Bassiri, said while speaking at a conference in Manhattan in July.
  • “Chances are we will not be able to mitigate all of the impacts of these changes, but we’re going to do everything in our power to do that.”

The other side: 

The new dynamic will force states to think more critically about how taxpayer dollars are being spent in Medicaid, said Brian Blase, president of Paragon Health Institute and a White House official during the first Trump administration.

  • “I want there to be a real budget constraint so [states] have to grapple with the actual cost of these programs,” he said.

Zoom in: 

Many states were already preparing austerity moves before President Trump signed the law. States faced with Medicaid budget crunches often cut or limit benefits they aren’t required to offer, like dental care or home- and community-based services.

  • Other strategies to adjust to the new era of Medicaid funding could include reducing Medicaid payment rates for providers or finding new sources of revenue like additional taxes.
  • A big focus is how well states will track whether recipients are either meeting a requirement to complete 80 hours of work, school or community service a month or are exempt from the rules.
  • Illinois, Missouri, Montana, North Dakota, New Mexico, Utah and Wisconsin have the highest risk of improperly kicking many eligible people off of Medicaid due to procedural issues, per a recent Georgetown Center for Children and Families report.
  • The report ranked state performance on eight key metrics, including how long Medicaid centers take to answer calls, how long the states take to process new applications and whether they renew eligibility automatically.

Between the lines: 

Congress authorized $200 million in federal funds to help states modernize their infrastructure for determining whether people are eligible for Medicaid.

  • HHS communications director Andrew Nixon said $100 million of the funds will be allocated equally among states, while the other half will be divvied up based on the share of enrollees in the state that will be subject to work requirements.
  • “All funding decisions will be guided by efficiency and legal compliance,” he said in an email.

States are still waiting for guidance and regulations from Medicaid administrators on some of the policy changes, and what kinds of technology they can use to ease the burden of reporting work hours and verifying who’s eligible.

  • Even timelines for getting systems running are up in the air. The budget law gives the Centers for Medicare and Medicaid Services discretion to let states have up to two more years to get work requirements up and running.

What we’re watching: 

What role health systems and Medicaid advocates have in states’ decision-making processes — and whether they can persuade state lawmakers to make up for some of the federal cuts with state funds.

  • “We’ve always said the cuts to Medicaid are … going to impact so many other parts of state budgets, and so that’s where the fight really is,” said Nicole Jorwic, chief program officer of Caring Across Generations, a nonprofit that advocated against Congress’ health care changes.

Expect More Hunger in America with Big New Rips to the Safety Net

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Policy, Healthcare Cuts, Healthcare Reform, Hunger, Medicaid, Medicaid Cuts, Medicaid Eligibility, Medicaid Funding, Medicaid Work Requirements, Public Good, Public Health, Public Interest, Public Welfare, Safety Net, Supplemental Nutrition Assistance Program (SNAP) • Tagged , , , , • Leave a comment

https://healthcareuncovered.substack.com/p/expect-more-hunger-in-america-with

The recently passed One Big Beautiful Bill Act, which makes deep cuts to the Medicaid program, also puts the food assistance that 41 million low-income Americans rely on in jeopardy. Many of the families currently getting food provided by  the Supplemental Nutrition Assistance Program (SNAP) stand to lose that support.  

SNAP may well disappear for some families as the federal government moves to trim it. “The cuts are massive and extremely cruel when families need more support, not less,” says Signe Anderson, senior director of nutrition advocacy, at the Tennessee Justice Center in Nashville. 

Government food assistance was established during the Great Depression, but it wasn’t until 1977 that the program became more accessible when the requirement that recipients had to pay for a portion of their food stamps was ended. Throughout its history, foes of the program have tried to dismantle it and may have succeeded as a result of provisions in the bill President Trump signed on July 4. 

The new legislation calls for cutting spending for food stamps by $186 billion through 2034. “Everyone on food stamps will be affected in some way, and many will lose benefits,” Anderson says. “I don’t think the Congress understands the level of necessity in the community for food, health care and mental health treatment, some for the rest of their lives.” 

One major change is being made to work requirements that have historically been part of the Medicaid program, which is administered and partially funded by the states. Anderson points out that under the new arrangements, participants may find the task of enrolling and staying enrolled more onerous. “We see a lot of people cut off already because too many life circumstances make it difficult for them to meet work requirements.”  

Indeed when you look at the changes to SNAP, the first word that might come to mind is ‘draconian.’

To receive benefits those new to the program, and those already on it who are between 55 and 64 and do not have dependent children or who have children 14 and older, will have to prove they work. Or they will have to volunteer at least 20 hours a week or enroll in training programs. Parents of school-aged children will now be required to work.

Some five million people, including about 800,000 children and about a half million adults who are 65 and older, could lose their food benefits.  

The programs the new law targets have been a lifeline for some. Nikole Ralls, a 43-year-old woman in Nashville, who was once a drug addict but now counsels others who need help, says, “I got my life turned around because of Medicaid and SNAP.”  

In a recent memo to state agencies administering the SNAP program, Agriculture Secretary Brooke Rollins said she was concerned about what was described as abuse of the waiver system by states, noting that the new approach for the SNAP program would prioritize work, education and volunteering over what the department characterized as “idleness and excessive spending.” 

Anderson said, “The public doesn’t understand what hunger looks like and are misinformed about how well-run and streamlined the SNAP program is.”   

“Most of the people who can, do work.  We have parents working two and three jobs,” Anderson said. For families in this predicament food banks, which have become default grocery stores, may be of little help.  They, too, are stretched thin. The Wall Street Journal reported food banks across the country are already straining under rising demand, and some worry there won’t be enough food to meet demand.

Health Insurance as a Share of Median Income by U.S. State

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment

https://www.visualcapitalist.com/mapped-health-insurance-as-a-share-of-median-income-by-u-s-state/

Health Insurance as a Share of Median Income by U.S. State

This was originally posted on our Voronoi app. Download the app for free on iOS or Android and discover incredible data-driven charts from a variety of trusted sources.

Key Takeaways

  • Vermont tops the list, with insurance costing 19.6% of median income.
  • New Hampshire residents spend just 4% of their income on health insurance, the lowest in the nation.

Americans pay wildly different amounts for health insurance depending on where they live. This map shows which states pay the most (and least) when health insurance costs are measured as a share of median income.

The data for this visualization comes from WalletHub. It analyzed silver-tier health plan premiums in all 50 states and compared them to local median incomes to determine cost burdens.

Vermont and West Virginia Lead in Cost Burden

In Vermont, residents spend 19.6% of their monthly income on health insurance, the highest share in the country. West Virginia follows closely at 18.8%.

The South and Mountain West Feel the Pinch

Many Southern and Mountain West states, like Mississippi, Wyoming, and Louisiana, also rank high in insurance cost burden. These regions tend to have poorer health outcomes and lower median incomes, exacerbating affordability issues. As Brookings notes, Medicaid expansion status and rural demographics heavily influence insurance markets in these areas.

New Hampshire and the Northeast Are Least Burdened

New Hampshire residents spend just 4% of their income on health insurance, the lowest in the nation.

Massachusetts, Maryland, and Minnesota also enjoy low cost burdens. These states often have robust state-run exchanges, higher incomes, and broader Medicaid expansion, all of which help reduce costs.

GOP faces ‘big, beautiful’ blowback risk on ObamaCare subsidy cuts

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, ACA, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Out of Pocket Expenses, Uncompensated Care, Underinsured, Uninsured • Tagged , , , , • Leave a comment
GOP faces ‘big, beautiful’ blowback risk on ObamaCare subsidy cuts

Medicaid cuts have received the lion’s share of attention from critics of Republicans’ sweeping tax cuts legislation, but the GOP’s decision not to extend enhanced ObamaCare subsidies could have a much more immediate impact ahead of next year’s midterms. 

Extra subsidies put in place during the coronavirus pandemic are set to expire at the end of the year, and there are few signs Republicans are interested in tackling the issue at all. 

To date, only Sens. Lisa Murkowski (R-Alaska) and Thom Tillis (R-N.C.) have spoken publicly about wanting to extend them. 

The absence of an extension in the “big, beautiful bill” was especially notable given the sweeping changes the legislation makes to the health care system, and it gives Democrats an easy message: If Republicans in Congress let the subsidies expire at the end of the year, premiums will spike, and millions of people across the country could lose health insurance.  

In a statement released last month as the House was debating its version of the bill, House and Senate Democratic health leaders pointed out what they said was GOP hypocrisy. 

“Their bill extends hundreds of tax policies that expire at the end of the year. The omission of this policy will cause millions of Americans to lose their health insurance and will raise premiums on 24 million Americans,” wrote Senate Finance Committee ranking member Ron Wyden (D-Ore.), House Ways and Means Committee ranking member Richard Neal (D-Mass.) and House Energy and Commerce Committee ranking member Frank Pallone (D-N.J.). 

“The Republican failure to stop this premium spike is a policy choice, and it needs to be recognized as such.” 

More than 24 million Americans are enrolled in the insurance marketplace this year, and about 90 percent — more than 22 million people — are receiving enhanced subsidies.

“All of those folks will experience quite large out-of-pocket premium increases,” said Ellen Montz, who helped run the federal ObamaCare exchanges under the Biden administration and is now a managing director with Manatt Health. 

“When premiums become less affordable, you have this kind of self-fulfilling prophecy where the youngest and the healthiest people drop out of the marketplace, and then premiums become even less affordable in the next year,” Montz said. 

The subsidies have been an extremely important driver of ObamaCare enrollment. Experts say if they were to expire, those gains would be erased.  

According to the Congressional Budget Office (CBO), 4.2 million people are projected to lose insurance by 2034 if the subsidies aren’t renewed.  

Combined with changes to Medicaid in the new tax cut law, at least 17 million Americans could be uninsured in the next decade. 

The enhanced subsidies increase financial help to make health insurance plans more affordable. Eligible applicants can use the credit to lower insurance premium costs upfront or claim the tax break when filing their return.  

Premiums are expected to increase by more than 75 percent on average, with people in some states seeing their payments more than double, according to health research group KFF. 

Devon Trolley, executive director of Pennie, the Affordable Care Act (ACA) exchange in Pennsylvania, said she expects at least a 30 percent drop in enrollment if the subsidies expire. 

The state starts ramping up its open enrollment infrastructure in mid-August, she said, so time is running short for Congress to act. 

“The only vehicle left for funding the tax credits, if they were to extend them, would be the government funding bill with a deadline of September 30, which we really see as the last possible chance for Congress to do anything,” Trolley said. 

Trolley said three-quarters of enrollees in the state’s exchange have never purchased coverage without the enhanced tax credits in place.  

“They don’t know sort of a prior life of when the coverage was 82 percent more expensive. And we are very concerned this is going to come as a huge sticker shock to people, and that is going to significantly erode enrollment,” Trolley said.  

The enhanced subsidies were first put into effect during the height of the coronavirus pandemic as part of former President Biden’s 2021 economic recovery law and then extended as part of the Inflation Reduction Act. 

The CBO said permanently extending the subsidies would cost $358 billion over the next 10 years. 

Republicans have balked at the cost. They argue the credits hide the true cost of the health law and subsidize Americans who don’t need the help. They also argue the subsidies have been a driver of fraudulent enrollment by unscrupulous brokers seeking high commissions. 

Sen. Bill Cassidy (R-La.), chair of the Senate Health, Education, Labor and Pensions Committee, last year said Congress should reject extending the subsidies. 

The Republican Study Committee’s 2025 fiscal budget said the subsidies “only perpetuate a never-ending cycle of rising premiums and federal bailouts — with taxpayers forced to foot the bill.” 

But since 2020, enrollment in the Affordable Care Act marketplace has grown faster in the states won by President Trump in 2024, primarily rural Southern red states that haven’t expanded Medicaid. Explaining to millions of Americans why their health insurance premiums are suddenly too expensive for them to afford could be politically unpopular for Republicans.

According to a recent KFF survey, 45 percent of Americans who buy their own health insurance through the ACA exchanges identify as Republican or lean Republican. Three in 10 said they identify as “Make America Great Again” supporters. 

“So much of that growth has just been a handful of Southern red states … Texas, Florida, Georgia, the Carolinas,” said Cynthia Cox, vice president at KFF and director of the firm’s ACA program. “That’s where I think we’re going to see a lot more people being uninsured.” 

Congress Could Force Patients in Rural America To Make Dire Medical Care Choices

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Bankruptcy, Financial Distress, Financial Instability, Financial Stewardship, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicaid, Medicaid Cuts, Rural Health, Rural Hospital, Uncompensated Care, Underinsured, Uninsured • Tagged , , , , • Leave a comment
https://healthcareuncovered.substack.com/p/congress-could-force-patients-in?utm_source=post-email-title&publication_id=255152&post_id=166944373&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

New Medicaid funding rules proposed by Congress this week would halt efforts at the state level to better fund rural hospitals and deliver services to the most vulnerable populations in those areas. You can be certain that the administrators and staff of those hospitals, as well as leaders of the communities they serve, are watching closely to see if the cuts are enacted. 

Lawmakers at the federal level are trying to make deeper cuts to Medicaid spending in an effort to lower the amount of deficit spending that would be created by President Trump’s spending plan. Trump has dubbed the plan his “big beautiful bill.” 

Feds Would Strip Rural Hospitals of Lifeline Funds

Republican members of the Senate Finance Committee this week released their version of the bill that would drain funding for rural hospitals, which rely heavily on Medicaid funds to treat patients. It’s estimated that 25 to 40 percent of services provided by such hospitals are funded by Medicaid.

The federal government and states share the up-front medical costs for Medicaid patients. The federal government then reimburses states up to 50 percent of their Medicaid spending every year.

Many states fund their portion of the cost by taxing entities that provide those services to Medicaid patients.

The latest proposal in Congress would not only restrict how many patients could receive benefits, but it would also stop states from implementing those provider tax programs to help fund Medicaid services provided to residents.

At the federal level, the thinking is that if states keep taxing providers to fund Medicaid services, then the federal government will have to keep reimbursing states a portion of those costs. 

The downside to that is many experts, along with several Republicans in Congress, namely Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and Josh Hawley of Missouri, have predicted it will decimate rural hospitals.

West Virginia Republican Sen. Jim Justice went a step further, saying that the plan to limit states’ use of provider taxes will “really hurt a lot of folks.” Despite that statement, Justice said he is OK with the freeze.

State Lawmakers Sound the Alarm

There are 39 states with at least three or more provider taxes used to help fund Medicaid services. Alaska is the only state with no such tax.

Some states, such as Ohio, have set up a new rural hospital fund using provider taxes to help rural hospitals deliver Medicaid services to patients.

Ohio Governor Mike DeWine and the Republican-led state legislature set up a pilot program called the Rural Ohio Hospital Tax Pilot Program. The measure would allow counties to levy a tax on their local hospitals that would then be used to fund Medicaid services.

DeWine said the pilot program would help ease the financial stress rural hospitals face in Ohio. The plan contained in Ohio House Bill 96 has the blessing of the Ohio Hospital Association.

That state fund reportedly would be neutered by the federal proposal. Ohio has at least three different provider taxes.  

A group of Republican state lawmakers recently sent a letter to their federal counterparts pleading with them to remove the bill language because it would “torpedo” plans to keep rural hospitals functioning.

The American Hospital Association, a 130-year-old trade group of more than 5,000 hospitals and health care providers, this month released the impact on rural hospitals if this plan went into effect.

 More than $50 billion would be lost by 2034, and more than 1.8 million rural Americans would lose health benefits.

Kentucky residents would be impacted the most, with 143,000 losing benefits, followed by 135,000 Californians. More than 86,000 Ohioans would lose Medicaid coverage under the plan by 2034, making it the third most impacted state.

To blunt the effects of the cuts, Collins reportedly is proposing the establishment of a $100 billion relief fund that could provide financial support to affected providers, rural hospitals in particular. Whether that or a similar but smaller fund will wind up in the final draft of the legislation apparently will be decided this weekend. Meanwhile, the Senate parliamentarian has ruled against many of the provisions of the Senate version of the bill, including the Finance Committee’s provider tax framework, which puts the whole thing in flux.

Senate leaders say they plan a long series of votes on amendments of the bill on Sunday. The “vote-arama” likely will go on throughout Sunday night and into Monday. If the Senate does pass its version of the bill, it will have to go back to the House. Lawmakers are under a self-imposed deadline to get the legislation to Trump by the July 4 holiday.

Federal Medicaid cuts imperil rural hospitals and residents

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Bankruptcy, Deferred Healthcare, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicaid, Medicaid Cuts, Medicaid Eligibility, Medicaid Funding, Nursing Home, Rural Health, Rural Hospital • Tagged , , , , • Leave a comment

https://www.ruralhealth.us/blogs/2025/06/federal-medicaid-cuts-imperil-rural-hospitals-and-residents-new-report-finds

Medicaid serves as a vital source of health insurance coverage for Americans living in rural areas, including children, parents, seniors, individuals with disabilities, and pregnant women. Congressional lawmakers are currently considering more than $800 billion in cuts to the Medicaid program, which would reduce Medicaid funding and terminate coverage for vulnerable Americans.

The proposed changes would also result in a significant reduction in Medicaid reimbursement that could result in rural hospital closures.

The National Rural Health Association recently partnered with experts from Manatt Health to shed light on the potential impacts of those cuts on rural residents and the hospitals that care for them over the next decade.

The report, Estimated Impact on Medicaid Enrollment and Hospital Expenditures in Rural Communities, provides insight into the impact on rural America at a critical moment in the Congressional debate over the future of the reconciliation package.

NRHA held a press conference on June 24 that can be accessed with passcode MBTZf4$H. NRHA chief policy officer Carrie Cochran-McClain discussed the findings with Manatt Health partner and former deputy administrator at CMS Cindy Mann and the real world implications of the details of this report with three NRHA member hospital and health system leaders

Report findings provide insight into the impact on rural America at a critical moment in the Congressional debate over the future of the reconciliation package.

The report shows the significant impact from coverage losses that rural communities will face given:

  • Medicaid plays an outsized role in rural America, covering a larger share of children and adults in rural communities than in urban ones.
  • Nearly half of all children and one in five adults in small towns and rural areas rely on Medicaid or CHIP for their health insurance.
  • Medicaid covers nearly one-quarter of women of childbearing age and finances half of all births in these communities.

According to Manatt’s estimates, rural hospitals will lose 21 cents out of every dollar they receive in Medicaid funding due to the One Big Beautiful Bill Act. Total cuts in Medicaid reimbursement for rural hospitals—including both federal and state funds—over the ten-year period outlined in the bill would reach almost $70 billion for hospitals in rural areas. 

Reductions in Medicaid funding of this magnitude would likely accelerate rural hospital closures and reduce access to care for rural residents, exacerbating economic hardship in communities where hospitals are major employers.

As a key insurer in rural communities, Medicaid provides a financial lifeline for rural health care providers — including hospitals, rural health clinics, community health centers, and nursing homes—that are already facing significant financial distress. These cuts may lead to more hospitals and other rural facility closures, and for those rural hospitals that remain open, lead to the elimination or curtailment of critical services, such as obstetrics.

“Medicaid is a substantial source of federal funds in rural communities across the country. The proposed changes to Medicaid will result in significant coverage losses, reduce access to care for rural patients, and threaten the viability of rural facilities,” said Alan Morgan, CEO of the National Rural Health Association.

“It’s very clear that Medicaid cuts will result in rural hospital closures resulting in loss of access to care for those living in rural America.”

A media briefing will be held on Tuesday, June 24, from noon to 1:00 PM EST to provide more information about the analysis. This event will feature representatives from NRHA, Manatt Health, and rural hospital leaders across the country. Questions may be submitted in advance, as well as during the press conference. To register for and join the media briefing, click on the Zoom link here.

Please reach out to NRHA’s Advocacy Team with any questions.

About the National Rural Health Association

NRHA is a non-profit membership organization that provides leadership on rural health issues with tens of thousands of members nationwide. Our membership includes nearly every component of rural America’s health care, including rural community hospitals, critical access hospitals, doctors, nurses, and patients. We work to improve rural America’s health needs through government advocacy, communications, education, and research. Learn more about the association at RuralHealth.US.

About Manatt Health

Manatt Health is a leading professional services firm specializing in health policy, health care transformation, and Medicaid redesign. Their modeling draws upon publicly available state data including Medicaid financial management report data from the Centers for Medicare and Medicaid Services, enrollment and expenditure data from the Medicaid Budget and Expenditure System, and data from the Medicaid and CHIP Payment and Access Commission. The Manatt Health Model is tailored specifically to rural health and has been reviewed in consultation with states and other key stakeholders.

New Tax Will Help Washington Residents Pay for Long-Term Care

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

Image result for long term care insurance

In other healthcare news from the Evergreen State, Gov. Inslee also signed a law this week that will provide a new long-term care benefit for state residents starting in 2025. In the furthest-reaching legislation of its type nationally, the new Washington law puts in place a payroll tax of 0.58 percent starting in 2022, and creates a year-long, $100/day allowance for state residents that can be used to pay for nursing home fees, at-home caregivers, and other long-term care needs.

Family members who are full-time caregivers can also receive compensation. Like other states, Washington spends a growing portion of its state budget on paying for long-term care for aging residents, putting a heavy burden on the finances of its Medicaid program that’s expected to worsen as the Baby Boom generation ages. In addition to nursing and caregiver services, the new benefit can also be used for in-home meals, housing repairs, and other services that impact health status.

As with its “public option” plan, Washington has taken the lead on another healthcare coverage issue that will eventually need to be addressed nationwide: the fact that seniors are entering retirement entirely unprepared for the amount they’ll need to spend on long-term care.

Medicaid currently pays for two-thirds of nursing home care and 60 percent of all long-term care costs, and no state is currently prepared for the amount of spending that will be required over the next 25 years. Almost no one buys long-term care insurance, which is unaffordable for most. Any serious attempt to expand coverage over the next few years must take on this critical issue.

 

 

Healthcare Triage News: Infants and the Medicaid Expansion

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , • Leave a comment

Healthcare Triage News: Infants and the Medicaid Expansion

Image result for Healthcare Triage News: Infants and the Medicaid Expansion

What can we do about infant mortality and disparities in health care? This week we take a look at a recent study in JAMA that may have an answer.