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This week’s In Focus鈥痵ection addresses post-election implications and initial considerations for understanding President-Elect Donald J. Trump鈥檚 possible federal healthcare policy agenda. Though healthcare was not the highest priority campaign issue, the president-elect and his team have signaled the policy agenda could include changes to the Affordable Care Act (ACA), Medicaid, and the nation鈥檚 public health programs. 

Additionally, President Trump鈥檚 first term policy agenda and how these policies fared, provide critical insights into the policy direction for his second term, including policies on Medicare drug pricing, ACA marketplaces, and interoperability. Also vital to understanding and planning for a second term will be the appointees to key healthcare positions at the Department of Health and Human Services and in the White House. 

Policy officials and specific policy agendas are still nascent, and 量子资源网, Inc., federal and state experts are continuing to monitor these developments. The remainder of this article focuses on a few key considerations for the Marketplace, Medicaid, and Medicare healthcare insurance programs heading into 2025. 

ACA Marketplace Issues to Watch 

President-Elect Trump signaled he is uninterested in revisiting a legislative initiative to repeal and replace the ACA. However, one of the major defining issues facing the president-elect and the next Congress is the temporary policy providing enhanced tax credits that lower ACA premiums, which expires at the end of 2025. This and other tax policies are very likely to be on the table, particularly as budget reconciliation is an available tool in unified government. 

Key considerations for healthcare stakeholders regarding the subsidy policy and federal funding for Marketplace outreach and education programs include: 

• The Congressional Budget Office (CBO)聽聽that extending the present enhanced subsidy policies would cost more than $300 billion over 10 years. The CBO also聽聽that ACA marketplace enrollment would drop from 22.8 million in 2025 to 18.9 million in 2026 if the subsidy policy is not renewed.聽
• The loss of subsidies would increase the number of uninsured individuals in the United States, but the size of the increase would depend on the state-specific landscape. For example, states that have not adopted the ACA鈥檚 Medicaid expansion for adults are expected to have a higher increase relative to states that have more expansive Medicaid eligibility. One potential approach is for lawmakers to modify the enhanced subsidy policy, rather than let it expire entirely.  
• Marketplace plans should be prepared for a change in the acuity mix of enrollees while providers should expect a change in their payer mix, with more uninsured individuals in states that have not expanded Medicaid. 

Federal and state policymakers may pursue a combination of alternatives to fill gaps in access to healthcare coverage and services. For example, the president-elect and incoming congressional leaders may focus on alternative coverage options and other state-driven reforms to Marketplace programs. Alternatives that could become part of the regulatory policy agenda include: 

• Supporting association health plans (AHPs) and high-risk pools 
• Reverting to a federal regulatory environment that supports short-term limited-duration healthcare insurance (STLDI) plans 
• Approving Section 1332 waivers to allow state-designed programs 

Medicaid Policy Outlook 

During Mr. Trump鈥檚 first term, one of his administration鈥檚 signature  was approving Section 1115 demonstrations that allowed states to apply work requirements to certain populations, including adult expansion populations. The first Trump Administration also revised the demonstration parameters for Section 1115 Institutions for Mental Disease (IMD), allowed coverage lockout for beneficiary noncompliance with premium payments, and  a pilot program to test interventions addressing health-related social needs (HRSNs). 

Key considerations for healthcare stakeholders regarding Medicaid flexibilities and funding include: 

• Officials in the first Trump Administration approved  Medicaid 1115 demonstration program to address HRSNs. President Biden鈥檚 Administration expanded these policies and approved demonstrations in more than 10 states, with additional state applications pending. Incoming officials may maintain the overall policy direction  with regard to HRSNs. However, they could pivot to narrow the scope of future state HRSN proposals. Another approach could include directing states to use in lieu of services (ILOS) authority in managed care delivery systems to address HRSN.  
• During President-Elect Trump鈥檚 first term, Centers for Medicare & Medicaid Services (CMS) officials prioritized work requirements and  for certain components of a state鈥檚 Medicaid program. Some states might consider revisiting these options, with modifications. If this policy direction is refreshed, federal and state officials would benefit from the foundational work conducted during the first term. 
• New CMS officials could prioritize work on transparency in Medicaid financing and reimbursement to providers. Federal officials, regardless of political affiliation, historically have sought to improve their understanding of the flow of Medicaid funding. Incoming officials could prioritize this issue again, which would have a varied effect on health plans and providers. 

Medicare Priorities: 

Relative to Marketplace and Medicaid, first term Trump Medicare policies were advanced with less conflict. Notable policy initiatives included a focus on healthcare-related challenges in , improving , and reducing  鈥攁ll of which were also cross-cutting issues that encompassed policy work beyond Medicare and could continue to be central to the next Medicare policy agenda.  

Key considerations for healthcare stakeholders regarding Medicare policy are as follows: 

• The president-elect鈥檚 first term  to Medicare Advantage (MA) plans sought to maximize enrollment in MA and encourage . It鈥檚 reasonable to expect second term CMS officials to maintain an overall favorable approach to MA too. Incoming officials could narrow their scrutiny of MA plans to bipartisan concerns, for example MA plans鈥� prior authorization policies. 
• While improving outcomes for dually eligibles beneficiaries generally is a bipartisan issue, state agencies, MA and Medicaid managed care plans, and other interested stakeholders should monitor the incoming Administration鈥檚 policy agenda for dually enrolled beneficiaries in Medicare and Medicaid. During the Biden Administration, CMS issued  for Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) to improve integration for the Medicare-Medicaid dually eligible population., Incoming Trump officials could revisit the approach, including the breadth of requirements and compliance timelines.  
• During his first term, President Trump was highly engaged in elevating concerns about  and HHS and CMS announced models and policies to  for patients. In his second term, however, the President could seek to rein in certain aspects of the Inflation Reduction Act (IRA), while revisiting some of his prior proposals. 

What to Watch 

The incoming Administration and its transition team are moving expeditiously to nominate new Cabinet Secretaries and to identify key staffers. The individuals appointed to departmental, agency, and advisory leadership positions will have significant leeway in shaping the federal and state healthcare policy landscapes 鈥� determining which existing policies to review and potentially revise, new policies to develop, and the approach to working with state and local officials and stakeholders. This includes the Secretary of Health and Human Services, CMS Administrator, Director of the Centers for Disease Control and Prevention, Food and Drug Administration Commissioner, and Director of the National Institutes of Health, all of which require Senate confirmation. Additionally, healthcare stakeholders should continue to monitor the leadership races for the House and Senate and the primary congressional committees with jurisdiction over healthcare programs. These leaders will be key to a second term Trump legislative policy agenda. 

Connect with Us 

This article focuses in on a subset of issues within Marketplace, Medicaid, and Medicare and in the overall healthcare sector. Our  features our experts discussing these and other insights on the election results. They provided an overview of what to expect from Congress and the Administration, focusing on key legislative priorities and executive actions.  

Join us for our next two webinars in the series exploring the election results:  

• November 19: The Future of Medicare Advantage: How the Election Results Impact the Program  
• November 20: Electoral Consequences: Impact on the ACA Marketplace 

The 量子资源网 Conference – Unlocking Solutions in Medicaid, Medicare, and Marketplace 鈥� was held in early October in Chicago, drawing a crowd of 350 participants hailing from all parts of the healthcare ecosystem. In the words of one attendee, what made the 量子资源网 conference unique was that 鈥渋t was very rare to have providers, CBOs, health systems, insurers, and public sector organizations in one place鈥�I gained significant value by viewing similar issues from different perspectives.鈥�

Attendees participated in plenary sessions and breakouts that were grounded in Medicaid, Medicare, and Marketplace, with each session extending beyond the traditional topics for these public health insurance programs. Attendees were challenged and inspired to consider the cross-cutting work underway to address health equity, the integration of housing into healthcare, innovative strategies for behavioral health coverage for adults as well as children and families involved in the child welfare system, and the opportunities for federally qualified health clinics to engage in value-based care delivery to improve outcomes.

Signature 量子资源网 discussions with health plan leaders and Medicaid directors also provided valuable insights that will help guide the next phase of innovative programs and technologies designed and deployed to improve health. Breakout sessions offered in-depth exploration across Medicaid/Duals, Medicare/MA, and Marketplace/ACA tracks, alongside discussions on demand for innovation, advances in treating sickle cell disease, and creative workforce strategies. The conference concluded with a panel that prepared attendees for policymaking in the post-election, post-Chevron deference landscape.

The 量子资源网 event created opportunities to learn and network with potential partners against the background of the city of Chicago skyline, as one participant put it, 鈥渁way from the daily craziness.鈥� The discussions were robust and focused on new ideas that can be deployed by stakeholders all trying to improve the accessibility, quality, equity, and value of healthcare.

Listed below are conference takeaways that will be of interest and relevant to the broader healthcare ecosystem:

These 鈥� and other takeaways and partnerships 鈥� will inform strategic, policy, programmatic and operational decisions at the hundreds of organizations represented at the 量子资源网 conference. They are also key points as we shape the conversations for the 2025 event.

Our second In Focus article reviews the recently proposed Notice of Benefit and Payment Parameters (NBPP) for 2026. The Centers for Medicare & Medicaid Services (CMS) , released October 10, 2024, describes the policy and payment changes that will affect the Affordable Care Act (ACA) markets in 2026. Public comments must be submitted to CMS by November 12, 2024. Key highlights from the proposed rule follow. 

Broker Oversight and Monitoring 

CMS proposes to increase oversight and accountability for brokers and agents that write policies through HealthCare.gov. In response to the  earlier this year of fraudulent actors reassigning broker designations and switching consumer enrollments without their permission or knowledge, CMS has already implemented several , including the  of 850 Healthcare.gov agents and brokers. CMS intends to build on these actions through the following interventions: 

• Clarify that lead agents, typically an agency owner or executive, are subject to the same rules as individual brokers, agents, and web-brokers and that enforcement action can be taken against the lead agents if they explicitly or implicitly condone misconduct or fraud 
• Broaden CMS鈥檚 authority to suspend broker and agent system access, inclusive of instances of suspected misconduct that affects eligibility determinations, operations, applicants, or systems 
• Update the model consent form to include documentation of the broker reviewing and confirming the accuracy of submitted application information with the consumer. 

Marketplace User Fees 

CMS proposes to increase the user fee collected to pay for administration of HealthCare.gov as follows: 

• Between 1.8 percent and 2.5 percent in 2026 for federally facilitated marketplaces (FFM) states, up from 1.5 percent of monthly premiums in 2025 
• Between 1.4 percent and 2 percent in 2026 for state-based marketplaces on the federal platform (SBM-FPs), up from 1.2 percent in 2025 

The proposed changes are due, in part, to uncertainty caused by the future of the enhanced premium tax credits that are set to expire at the end of 2025. The enhanced premium tax credits are the driving force behind the  in nationwide marketplace enrollment to more than 21 million people in 2020 from 11.4 million in 2020. If not extended, or if it takes past March 2025 for Congress to act, CMS has indicated the user fees will increase in 2026 to 2.5 percent for FFM states and 2% for SBM-FPs to accommodate expected enrollment declines. Notably, after several years of significant decreases, CMS is proposing to increase the user fees above 2025 levels regardless of the outcome of the enhanced premium tax credits. 

Plan Limits for Non-Standard Plans 

CMS proposes to clarify rules limiting the number of non-standardized plans an issuer can offer through HealthCare.gov (two or less in 2025). The limit is applied per product network type (e.g., HMO, PPO), per metal level, per service area, per inclusion of adult/pediatric dental and/or vision benefits (with additional exceptions, starting in payment year (PY) 2025, for plans with specific design features that would substantially benefit consumers and meet other requirements). To maximize the number of non-standardized plans offered on HealthCare.gov, an issuer could offer up to 16 plans per metal level and network type in a given service area by creating every combination of adult dental, pediatric dental, and adult vision (or even more, if plans meet the exception requirements). 

Though CMS does not limit the number of standardized plan options an issuer offers on HealthCare.gov, they propose reinstating a meaningful difference standard to prevent consumer confusion and unnecessary plan proliferation. The proposed standard is similar to the removed standard from 2019; for plans in the same metal level, product type, and service area, a reasonable consumer needs to be able to identify at least one material difference in benefit coverage, provider networks, and/or formulary. 

New Premium Payment Threshold Options for Issuers 

CMS proposes new options for issuers to avoid triggering late payment grace periods for consumers who make most but not all of their premium payment to minimize termination of coverage for consumers who owe a small amount. The options include: 

• The current option of a 鈥渞easonable鈥� percentage of net premium. CMS proposes codifying 95 percent as the minimum threshold. 
• New proposals of as low as 99 percent of gross premium and a fixed-dollar threshold of $5 or less. 

CMS is also considering limiting issuers to offering just one payment threshold option鈥攅ither fixed-dollar or percent of premium鈥攖o avoid consumer confusion. 

Increased Transparency for State-Based Marketplaces 

CMS proposes new initiatives to promote transparency into state-based marketplace (SBM) program operations. These initiatives include: 

• Publishing State Marketplace Annual Report Tool (SMART) submissions, which are used to monitor SBM compliance with select eligibility and enrollment, program integrity, and financial reporting requirements. SBMs must annually participate in independent programmatic and financial audits as part of SMART. CMS proposes to make the 2023 SMART submissions public in spring 2025. 
• Expanding the disclosure of SBM information to include data collected but not currently published, including details on SBM eligibility, enrollment, and plan certification policies as well as Navigator program spending, call center metrics, and website traffic data. 

SBMs already are required to publish programmatic and financial audit summaries and generally publish robust data and information on their program operations through public reports and meetings; however, this information is neither centrally located nor consistently published across all SBMs. 

Key Considerations 

The proposed 2026 NBPP would build on previous actions that CMS has taken to address fraudulent broker and agent activity and to shore up financial sustainability of Healthcare.gov operations in light of uncertainty about the enhanced premium tax credits. It also seeks to make clear how plan variations adding dental or vision benefits factor into HealthCare.gov plan limits and gives issuers new premium payment threshold options. Lastly, it proposes new transparency requirements for SBMs. Interested stakeholders, including SBMs and issuers, should monitor how these proposed changes will affect consumers, operational processes, product strategy, and financial sustainability. 

Connect With Us 

The 量子资源网, Inc., team has the depth, experience, and subject matter expertise to assist with tailored analysis and the modeling capabilities to assess the policy impacts to consumers, marketplaces, and issuers. If you have questions or want to discuss the proposed rule, contact our featured experts below.

For additional information on elements of the proposed NBPP not discussed here, Wakely Consulting鈥檚聽white paper, , highlights the proposed changes to the Risk Adjustment program, Medical Loss Ratio, and the Actuarial Value Calculator, among other changes.聽

Given that 50 percent of Americans have publicly funded health insurance鈥攊ncluding Medicare, Medicaid, or Affordable Care Act Marketplace plans in which many premiums are subsidized鈥攖he need is growing for innovations that will yield better quality at lower total cost. The 量子资源网 (量子资源网) Fall Conference, , offers an agenda that dives deeply into the latest innovations and opportunities in these critical programs. Focused on improving collaboration and information sharing, the event will explore strategies and practical solutions to reduce health disparities and enhance outcomes for aging, disabled, and chronically ill people.

The federal government recently created the Advanced Research Projects Agency for Health (ARPA-Health), which is charged with supporting the development of high-impact solutions to improve health outcomes. We are fortunate to have as our keynote speaker from ARPA-H. We have asked him to share his thoughts on why innovation in the public healthcare space is critical.

Dr. Sanghavi will kick off the 量子资源网 conference with a discussion on how ARPA-H initiatives are intended to support new solutions to modernize today鈥檚 healthcare landscape鈥攏ot only with technology, but also through changes in our approaches to healthcare delivery and payment.

Only a month before the November elections, the 量子资源网 conference presents a valuable opportunity to engage with healthcare leaders across the public and private sectors to hear how they are thinking about potential policy and regulatory changes that could affect publicly funded programs and supplemental coverage. Attendees will take home insights and actionable ideas to drive improvements in health and well-being. Join us to shape the solutions that will impact the future of healthcare!