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Medicaid cuts take up oxygen, but the ACA could be gutted, too

Picture of Action Benefits Action Benefits Jun 05, 2025

Individual/families

5:28

If the “One, Big, Beautiful Bill” escapes the Senate as-is, Marketplace enrollment could be slashed by a third, losing about 8 million of the current 24 million enrolled nationwide. The uninsured rate would rise, leaving Marketplace health insurance agents with a significant gap in their book of business. Here’s what’s proposed, and what you can do.

The big picture:

The cuts wouldn’t be due to a single, sweeping policy, which might explain why they’re getting less media attention. But, taken together, they’d be drastic. What are the component parts?

First, while not part of the bill, Congress has made no progress toward extending the expanded advanced premium tax credits. That expansion occurred during the pandemic era, with the passage of the American Rescue Plan and the Inflation Reduction Act. Without any action, expanded credits will expire at year’s end, leading to an estimated drop of 4.4 million enrollees. Consumers’ responsibility for premiums, on average, would rise about 75%.

Second, the One Big Beautiful Bill has several technical provisions that the Congressional Budget Office projects will result in the loss of another 2.2 million enrollees. Several amendments were added by the House Ways and Means committee; their impacts are still being scored by the CBO as of this writing.

What are the ACA-related changes in the One Big Beautiful Bill?

The megabill contains several provisions that would reshape eligibility and enrollment in the Marketplaces. Several of these provisions mirror proposals in the off-cycle Marketplace rule proposed earlier this spring. Of note:

Policies affecting eligibility and enrollment	Policies affecting tax credits	Policies affecting the broader market
The open enrollment period would now end on December 15	Provisional eligibility for tax credits would be removed: Enrollees would pay their full premium while verification of income, immigration status, health coverage, place of residence, and family size is verified. Effectively, passive renewals would end.	Insurers would be allowed to require payment of the entire first month's premium to effectuate coverage; they may also require any past-due premiums to be paid before effectuating a new plan.
The Special Enrollment Period for people with incomes up to 150% of FPL would be eliminated; states would be forbidden from creating their own income-related SEPs	Consumers would be required to file and reconcile each year; failure to do so would remove eligibility for premium tax credits	CSR-eligible enrollees in a Bronze plan would no longer automatically be enrolled in a Silver plan during the next open enrollment period
Enrollees using any SEP would be required to prove eligibility before enrolling	Individuals with no income or family size data on file with the Treasury Department would no longer be able to self-attest to these; additional documentation would be necessary	DHHS would resume paying cost-sharing reduction payments to insurers
Marketplace Eligibility for refugees and asylum seekers, who have been using the Marketplaces since inception, would be revoked.	Consumers would no longer receive an automatic 90-day extension to verify income	Actuarial value variation would be expanded to -4%/+2%
Eligibility for DACA recipients is also revoked	Enrollees with zero premium responsibility would be required to actively re-enroll each year, or face a $5 reduction in their tax credits per month
	Requires tax credit recipients to repay excess credits regardless of income; consumers in non-Medicaid expansion states may end up paying back the entirety of their APTCs if they did not make enough money to qualify for those credits

How would life change for health insurance agents under the One Big Beautiful Bill?

In short, you’d have fewer prospects and customers and more work to do – all in a compressed timeline.

Right off the bat, your prospect pool is narrowed by the 1 million or so asylees and refugees that use Marketplace coverage; DACA recipients would also be excluded. Folks whose incomes drift between 138% of FPL and 150% of FPL would no longer have an SEP, meaning you’d have fewer mid-year enrollments. And, speaking of SEPs, you’d need to verify that a consumer had their birth certificates, marriage certificates, or loss of coverage documentation all in order before they even apply --- making business that much harder.

Once someone is enrolled, it’ll be harder to keep coverage and tax credits. Auto-renewals would effectively be eliminated, as consumers of all income levels would need to verify their eligibility each year. And, you’d need to remind consumers to file and reconcile their taxes and tax credits each year, lest they lose their eligibility for those credits.

And, in case it wasn’t clear above, you’d be doing all your renewals between November 1 and December 15.

What’s next?

The megabill currently sits in the Senate. The majority party has self-imposed a deadline of July 4 to shepherd the bill through the budget reconciliation process and get it to the president’s desk for signature.

If you’re a health insurance agent working in any Marketplace, you still have time to influence your Senators and Representatives, as they’ll all have to take at least one more look at the bill.