This publication is part one of a two-part series outlining federal changes to the ACA Marketplace.
In July, Congress passed a sweeping budget reconciliation bill that cements the largest cuts to health care and food security in US history. Supported by all four members of West Virginia’s Congressional delegation, these cuts will impact families, communities, and the state’s economy and budget. While much of the focus on this legislation has centered on Medicaid and SNAP, there are also significant cuts to the Affordable Care Act’s (ACA) health care Marketplace, which helps nearly 24 million Americans receive health insurance, including nearly 70,000 West Virginians. It has played a key role in decreasing the number of people in the state who are uninsured while providing access to necessary care.
Overall, this legislation makes health care significantly less accessible, whether because it is more expensive or more exclusive. Many of the unprecedented changes will be difficult for enrollees to navigate. To add insult to injury, the ACA Navigator program, which helps people enroll in the Marketplace and navigate complicated processes, will lose 90 percent of their funding by the end of August 2025. This cut will drastically reduce their ability to help people access the care they need.
H.R. 1 allows enhanced ACA subsidies to expire (effective January 1, 2026): During the COVID-19 public health emergency, Congress made Marketplace coverage more affordable by increasing the amount of subsidies (also known as tax credits or advance premium tax credits) that enrollees were eligible for. The Marketplace serves people who cannot get health insurance through a job, Medicare, or Medicaid; income-based subsidies help make health insurance on the Marketplace more affordable—but those enhanced subsidies will expire at the end of this year without Congressional action.
Since 2022, West Virginia’s Marketplace has more than doubled in size (from roughly 23,000 people to just over 67,000), in large part due to its affordability in the wake of the public health emergency. If Congress does not extend these credits, over 67,000 West Virginians will see their health insurance premiums increase by an average of 133 percent or $1,400 annually. This is expected to result in 15,000 West Virginians losing their health insurance because they can no longer afford it.
Congress still has time to extend these enhancements and make them permanent before open enrollment starts on November 1, 2025.
H.R. 1 bars people who fail to meet Medicaid work reporting requirements from receiving ACA subsidies (effective January 1, 2027): While the Marketplace faces significant changes, Medicaid and other safety net programs do, too. For the first time in program history, Medicaid will nationally implement work reporting requirements (or job loss penalties) for many enrollees, including parents of children over the age of 14 and those recently laid off. While most Medicaid recipients already work or meet an exemption, proving those things repeatedly is often a confusing and challenging multi-step process. An estimated 50,000 to 110,000 West Virginians are at risk of losing their health coverage because of this requirement—despite many of them meeting it.
The bill also bars people who lose their Medicaid coverage because of these work reporting requirements from receiving subsidies to help them afford Marketplace coverage. Combined, these policies make health care less accessible for thousands of West Virginians by using difficult-to-navigate bureaucratic red tape.
H.R. 1 eliminates certain immigrants’ ability to receive ACA subsidies (effective January 1, 2026): Medicaid and other safety net programs do not allow undocumented immigrants or permanent residents (including green card holders) who have been in the country for fewer than five years to receive benefits. Prior to this legislation, documented immigrants who would qualify for the traditional Medicaid program if not for the five-year bar could enroll in the Marketplace and receive subsidies.
Starting in 2026, this population will no longer be able to receive subsidies for the Marketplace. Because they are also not eligible for Medicaid due to their immigration status, this population will not be able to receive health insurance unless their employers offer it at an affordable price or they pay for a Marketplace plan out of pocket. It is unclear how many West Virginians this aspect of the legislation will impact, but it is apparent that this change will deeply impact immigrant families in West Virginia, many of whom will have no other health insurance options.
H.R. 1 eliminates subsidy repayment limits (effective January 1, 2026, with impact during the 2027 tax season): To determine the amount of subsidies that a person or family qualifies for, enrollees must estimate their projected income for the year that their health insurance plan will cover. For many West Virginians, especially for contract workers and self-employed people, it can be difficult to predict their incomes and other unexpected life changes. In the past, if their actual income was higher than what they projected, they were required to repay excess subsidies—but importantly, there were limits to protect people from large, unexpected repayment burdens.
Starting during tax season 2027, enrollees who underestimated their incomes in 2026 will be required to repay the entire excess subsidy that they received. This policy change has potential to put many people at significant risk of financial instability amid other life changes, including divorce or receiving Social Security disability benefits.
H.R. 1 eliminates ACA subsidies for people who enroll via an income-based special enrollment period (effective January 1, 2026 and expires January 1, 2027): In March 2022, the Marketplace added a special enrollment period for people with low-incomes. For the first time, people with incomes below 150 percent of the federal poverty line (about $20,300 annually for a single person) could enroll in the Marketplace and receive subsidies outside of the open enrollment period without meeting another qualifying life event.
Starting during open enrollment for 2026 plans, people with low incomes must meet another qualifying life event to receive subsidies for health insurance outside of the open enrollment season. Furthermore, a June regulation eliminates the low-income special enrollment period for 2026, meaning that even without qualifying for subsidies, people who do not meet another qualifying life event cannot receive coverage via the Marketplace at all. The provisions of the June regulation will be further detailed in part two of this series.
Combined, the cuts to Medicaid and the ACA Marketplace are expected to leave West Virginia with $1 billion fewer federal dollars every year. H.R. 1 will impact every West Virginian, even if they do not rely on Medicaid or the ACA Marketplace for their health insurance. This legislation will incur a significant cost to families and the state: it will result in thousands of jobs lost, hospital and clinic closures, fewer available services, and worse quality of life for many West Virginians. It will harm the very economy it claims to support and push people into debt. It will make health insurance more expensive for people in employer-sponsored health insurance plans.
The deepest cuts will not occur for several years, giving Congress the opportunity to reverse course and work toward improving health care outcomes via access and affordability.
