By Karen Davenport, Stacey Pogue, and Sabrina Corlette
With the passage of H.R.1, the House of Representatives’ version of the budget reconciliation bill that will advance President Trump’s domestic policy agenda—specifically, extending tax cuts for wealthy individuals and corporations while making massive cuts to food assistance, health coverage and access, and green energy investments—all eyes turned to the Senate. In mid-June, the Senate Finance and Health, Education, Labor, and Pensions Committees released legislative language that will be foundation for Marketplace changes in the Senate’s budget bill. While the Senate language purports to ease the enrollment barriers to Marketplace coverage that are a hallmark of the House bill, it’s really a case of “second verse, same as the first.” The Senate language would still leave Marketplace enrollees vulnerable to unexpected premium bills and at risk of losing their health insurance coverage.
Recapping the House Bill: Coverage Losses Driven by Enrollment Barriers
The House-passed bill will reverse the coverage and access gains made possible by the Affordable Care Act health insurance Marketplaces by relying on several key strategies. First, it will increase Marketplace enrollees’ costs for holding health insurance coverage. Second, it will create new paperwork barriers to enrollment, thus ensuring that fewer eligible individual and families are able to enroll in health insurance. And third, it prohibits certain people from enrolling in Marketplace coverage altogether. All in all, the Congressional Budget Office estimates that approximately 4 million people will lose coverage as a direct result of the provisions in the House-passed bill.
CHIR has previously published on the overall impacts of the House-passed bill, taken a deep-dive into some of its most problematic provisions, examined which enrollees could be lost in a paperwork thicket, considered how the bill hamstrings state-based Marketplaces (SBMs), and identified lost opportunities to deter actual, rather than imagined, enrollment fraud.
Heralded Fixes Fail to Stem Likely Coverage Losses
The Senate Finance Committee changed the House language to try to address acknowledged problems with the House bill. For example, the Finance Committee creates new administrative discretion for the Treasury Secretary to ensure that people who experience a change in family size during the year—such as having a baby—do not lose their premium subsidies and, by extension, their health insurance. Should the Treasury Secretary exercise this discretion, this provision could address an important coverage barrier in the House bill. On the other hand, “missing” provisions in the Senate language, when compared with H.R.1, are also found in the “Marketplace Integrity” rule the Centers for Medicare & Medicaid Services (CMS) proposed on March 19, 2025. In some cases, these provisions would take effect even earlier under the proposed rule. These enrollment barriers—such as shortening the duration of annual Marketplace Open Enrollment—could still be added to the reconciliation bill before it reaches the Senate floor, and the regulatory proposal will presumably be finalized soon. Whether these provisions are implemented through regulation or a statute, consumers will encounter the same red tape and higher costs.
Little Daylight Between House and Senate Legislation
Most importantly, the overall approach of the Senate committees’ reconciliation proposals closely mirror the House reconciliation bill. As seen in the table below, both efforts seek to reduce Marketplace enrollment by creating new and unexpected premium costs, raising new barriers to enrolling in and keeping coverage, and blocking certain individuals from enrolling in Marketplace coverage.
Enrollment Barriers to Marketplace Coverage in Reconciliation Legislation
| House | Senate | |
| Requires enrollees who are eligible for premium subsidies to pay full ACA premiums when income verification problems arise | ✓ | ✓ |
| Prohibits asylees, victims of trafficking, DACA recipients, and some legal permanent residents from enrolling in Marketplace coverage | ✓ | ✓ |
| Limits states’ ability to simplify enrollment processes in State-based Marketplaces | ✓ | ✓ |
| Ends auto-enrollment by requiring Marketplace enrollees to affirmatively initiate re-enrollment for the following year | ✓ | ✓ |
| Creates new paperwork barriers to ACA coverage | ✓ | ✓ |
| Increases consumers’ cost of coverage, leading to large coverage losses | ✓ | ✓ |
Takeaway
Like its House companion, the Senate reconciliation bill threatens Marketplace enrollees’ affordable health coverage and the access to care that health insurance coverage makes possible. Under both proposals, Marketplace enrollees will face significant new costs and barriers to coverage.
