Here are the top 10 ACA-related changes embedded in the 2025 “One Big Beautiful Bill Act” (OBBBA) that directly impact the Affordable Care Act and Medicaid:
1. Expiration of Enhanced ACA Marketplace Subsidies (end of 2025)
The expanded premium credits from pandemic-era laws will expire, reverting to pre-2021 levels—raising average premiums from around $113 to $619 per month, and potentially causing millions to lose coverage.
2. Shortened Open Enrollment Periods
Annual ACA enrollment now ends on December 15, not mid-January, reducing consumer access and flexibility.
3. Limits on Special Enrollment Periods (SEPs)
Removes year-round low-income SEP (≤150% FPL) and restricts other SEP triggers—making it harder for people to sign up during the year.
4. Elimination of Automatic Re-Enrollment
Automatic renewals are eliminated; enrollees face a $5 monthly fee for zero-dollar plans if they haven’t re-verified eligibility.
5. Stricter Documentation and Income Verification
Requires pre‑enrollment proof of income, residency, immigration status, etc., with no subsidy until documents are verified.
6. Removal of Repayment Caps for Excess Tax Credits
Removes limits, so enrollees who received too much subsidy may owe full repayment on mismatched tax credits.
7. Exclusion of DACA Recipients from ACA Marketplace
“Lawfully present” definition no longer includes DACA, so they’re now explicitly ineligible for credits and Marketplace coverage.
8. Prohibition on ACA Funds Covering Gender-Affirming Care
Medicaid and ACA plans can no longer cover gender-transition services (puberty blockers, hormones, surgeries) under the Crenshaw Amendment.
9. New Medicaid Work Requirements & Frequent Re-Verification
Adults 19‑64 in ACA-expansion Medicaid must work or volunteer 80 hrs/month. States must re-check eligibility twice yearly—a shift from annual reviews.
10. Increased Medicaid Cost-Sharing & Provider Tax Limits
Medicaid expansion enrollees (above FPL) now face cost-sharing up to 5% of income. States also face stricter caps on provider taxes, potentially hurting hospital funding.
Why These Matter
The rollback of subsidies and automatic renewals alone could leave 4-4.2 million without coverage; combined with Medicaid cuts, up to ~17 million Americans are at risk.
New administrative barriers – like work requirements, frequent re-verification, and documentation – are expected to cause coverage churn even among eligible individuals.
Banning gender‑affirming care and excluding DACA/immigrant populations signal a shift in eligibility and benefits, not just cost savings.
Overall Impact Summary
Coverage Loss: Tens of millions lose insurance — combining subsidy expiration and Medicaid rollbacks.
Cost Increases: Remaining enrollees face higher premiums, deductibles, fees, and out-of-pocket spending.
Access Barriers: Shorter enrollment periods and tighter qualification rules make obtaining and maintaining coverage harder—especially for low-income, immigrant, and vulnerable.