The Waiting Room | What Health Care Changes Does Trump Have in Store for 2027?
Millions have seen health care premiums soar this year. So is any relief in sight for next year?
Charles Gaba is a health care analyst who tracks policy and politics at ACASignups.net. Subscribe to his Substack!
In the last edition, I went over the various options available for some Americans to enroll in healthcare coverage now that the official 2026 ACA Open Enrollment Period has ended.
This time around I’m gonna go over the changes that the Trump Regime is proposing for next year … and a lot of them aren’t pretty at all.
Greetings, Lincoln Square readers!
The good news is that I also have a CALL TO ACTION: You can submit public comments on all of these proposed changes (using this form) through March 13th.
The Patient Protection & Affordable Care Act includes a long list of codified instructions about what’s required under the law. However, like any major piece of legislation, many of the specific details are left up to the agency responsible for implementing the law.
While the PPACA is itself a lengthy document, it would have to be several times longer yet in order to cover every conceivable detail involved in operating the ACA exchanges, Medicaid expansion and so forth. The major provisions of the ACA fall under the Department of Health & Human Services (HHS), and within that, the Centers for Medicare & Medicaid (CMS).
Every year, CMS issues a long, wonky document called the Notice of Benefit & Payment Parameters (NBPP) for the Affordable Care Act. This is basically a list of proposed changes to some of the specifics of how the ACA is actually implemented for the upcoming year. Some of the changes are minor tweaks; some are major. Some are fairly simple to understand; some get extremely technical & wonky.
The proposed 2027 NBPP was recently released by CMS. The full official document is 577 pages long … over 200,000 words total.
For comparison, the first volume of the Lord of the Rings trilogy, The Fellowship of the Ring, runs around 187,000 words.
While there are dozens of proposed changes, I’m going to try and focus on the most urgent ones; you can view my more detailed explainers here, here and here; and if you want an even deeper dive, you can check out even wonkier explainers by Katie Keith & Matthew Fiedler at Health Affairs here, here and here.
NOTE: Any time you see a reference by CMS to “WFTC legislation,” that stands for “Working Families Tax Cut legislation” and is simply a rebranding of Trump’s so-called “One Big Beautiful Bill Act“ ... aka the Big Ugly Bill.
“Expand Regulations on Marketing Practices”
CMS proposes to strengthen regulations on marketing practices for ACA exchange plans, including cracking down on carriers/vendors claiming to pay people to enroll, making false claims about zero-cost insurance, misstating enrollment deadlines, etc.
For the most part, this sounds perfectly reasonable. Unfortunately, digging through the details of the “marketing practices” section, I came across this bit:
“We also propose to remove language from § 155.220(j)(2)(i) that defines the term “sex” to include sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity; and sex stereotypes.
Yep, like every other are of society, the Trump regime is doing everything it can to completely erase transgender people from existence.
“Provider Access and Essential Community Provider (ECP) Certification Reviews”
Essential Community Providers (ECPs) are healthcare providers who serve low-income and/or medically underserved communities; they include Federally Qualified Health Centers (FQHCs), Indian Health Service providers, Community Health Centers, Family Planning Clinics and so forth.
In 2025, insurance carriers had to contract with at least 30% of ECPs in their area in order to qualify for being listed on the ACA exchange. Trump 1.0 dropped this down to 20%. The Biden Administration beefed it up to 35%...and now Trump 2.0 is cutting it back to 20% again.
In addition, the Trump regime is removing time & distance requirements which are currently in place to “ensure a sufficient choice of providers” (that is, carriers are currently required to prove that a certain number of in-network healthcare providers of various types are included within a certain physical distance of anyone living in the coverage area, and that enrollees are able to secure appointments with those providers within a given time frame.
This would likely mean having to drive a lot further to get to your specialist or having to wait a lot longer to get an appointment.
“QHP Certification of Non-Network Plans”
CMS proposes to allow non-network plans to receive QHP certification beginning with plan year 2027.
With networked plans, healthcare providers have to charging specific prices for specific services. With non-network plans, they can charge pretty much whatever the hell they want, but the insurance plan will only cover a certain amount of that, leaving the enrollee to foot the balance of the bill, whatever it is.
🚨 DANGER, WILL ROBINSON.
Traditional networked plans include specific providers. Non-networked plans mean that it’s up to you to hunt down the provider on your own. This is touted by the Trump regime as “empowering enrollees” to “shop for lower prices,” because everyone knows that when you’re having your gall bladder removed you want to go with the lowest bidder, and who doesn’t like spending hours on the phone trying to decide on the best place to have your kidney dialysis?
In addition, without a network, your ear, nose, and throat specialist may not have any coordination or record sharing agreement with your internist.
“State Exchange Enhanced Direct Enrollment Option”
CMS proposes to allow states to “adopt a private sector-based approach” for setting up a state-based ACA exchange platform, in which they would “rely exclusively on web brokers to operate the consumer-facing website.”
Put simply, they want to allow states to completely privatize their ACA exchange websites.
Right now, every state’s ACA operations are hosted either by the federal exchange (HealthCare.Gov, which 30 states currently use) or a government-operated state-based exchange (20 states and D.C.) such as Covered California, NY State of Health, Pennie, etc.
In addition, however, there are also authorized third-party web broker sites like Health Sherpa and Stride Health which plug into the federal exchange backend for people to enroll in ACA exchange plans (including tax credits for those eligible).
🚨 DANGER, WILL ROBINSON.
If this NBPP rule goes through, some states would be allowed to go without having ANY official, government-operated ACA exchange platform AT ALL. This is a massive red flag.
“Limit APTC Eligibility to “Eligible Noncitizens” & disallow it for those below 100% FPL who are ineligible for Medicaid due to immigration status”
CMS proposes requiring individuals to be defined as “eligible aliens” in order to be eligible for ACA premium tax credits or Cost Sharing assistance as well as requiring all exchanges to verify their “eligible alien” status.
They would further extend this to the Basic Health Plan (BHP) programs operating in DC, MN, NY & OR (which have nearly 1.8 million enrollees).
In addition: Most lawfully-present immigrants in the United States aren’t eligible for Medicaid—regardless of their income—until they’ve lived in the U.S. for at least five years. If their income is below 100% FPL, however, there’s a provision of the ACA which—until now—allowed them to be eligible for ACA tax credits instead.
Unfortunately, this provision is now gone due to the Big Ugly Bill.
Beginning in 2026, the OBBBA eliminated a statutory exemption that had allowed certain lawfully present immigrants whose income is below 100 percent FPL to qualify for PTC …
Broader restrictions will take effect in 2027 when the OBBBA newly limits PTCs to lawful permanent residents (i.e., green card holders), certain Cuban and Haitian immigrants, and individuals living in the United States through a Compact of Free Association.
So who isn’t eligible for ACA tax credits any longer (or won’t be starting next year) under the OBBBA? Well, in addition to those legally present for less than five years, others who are about to be royally screwed include refugees, parolees, those granted asylum and even victims of domestic abuse and human trafficking.
🚨 DANGER, WILL ROBINSON.
Let me repeat that: Victims of domestic abuse and human trafficking will no longer be eligible for ACA subsidies.
Around 237K federal exchange enrollees have already lost eligibility this year, and another ~1.23 million will starting in 2027. All told, that’s around 1.5 MILLION lawfully present ACA exchange enrollees will no longer qualify for ACA subsidies.
It gets worse:
The new “eligible noncitizen” definition for the BHP programs would result in BHP funding being cut by over $100 million per year.
This is a major part of the reason why New York, which currently has over 1.7 million residents enrolled in their expanded BHP program, announced last fall that they’re going to have to massively shrink the program’s scope starting in July, resulting in around 450,000 New Yorkers currently enrolled in the program being kicked off of it.
“Audit and Compliance Review Authority Changes”
As Katie Keith explains at Health Affairs, HHS already has some authority to conduct oversight of insurance carriers participating in the ACA exchanges; this would greatly expand that authority:
This proposal would increase HHS’s authority over QHP insurers and potentially enable HHS to assess compliance with a wider range of provisions related to eligibility, enrollment, or plan design. As an example, HHS notes that current requirements do not extend to grace period requirements in subpart C even though noncompliance with these standards—and “other enrollment and payment requirements”—could lead to improper payments.
In addition to grace periods, subpart C includes a wide range of QHP certification standards with an ostensible link to APTC, CSR, and user fee programs. (Subpart C includes rules to implement Section 1303’s requirements regarding the segregation of funds for abortion services, but Section 1303(b)(2)(E) of the ACA makes clear that state insurance commissioners, not HHS, are responsible for ensuring that QHP insurers comply with these requirements.)
And that’s almost certainly what this is about:
Under the ACA, insurance policies which include coverage of abortion services are required to separate out $1 per enrollee per month into a separate account; the money in that account can only be used to pay for abortions and for no other purpose, and no other funds can be used to pay for it.
The reason for this absurdly convoluted policy is to ensure that not a single dollar of federal funds (i.e., tax credits) is used to pay for an abortion, in order to comply with the Hyde Amendment.
Let’s say you enroll in a policy which includes abortion coverage. The unsubsidized premium is $500/month, and you qualify for $400/month in federal tax credits; you pay the remaining $100. A few months into the year, you have an abortion performed. It’s therefore hypothetically possible to argue that a portion of that $400/mo tax credit went to pay for the abortion. Therefore, the ACA requires $1/month of the $500/mo premiu to be separated out from the remaining $499.
This is absolutely bonkers, of course, but it’s how the ACA has operated since 2014. There are dozens of special bank accounts set up by insurance carriers around the country specifically designed to be “abortion funds.” The money in them can’t be used for anything else.
As absurd as that may sound already, it gets worse: A few years back, I did some basic math and concluded that, since there’s likely far more money going into these funds each year than is ever paid out in abortion services, there was likely around $200 million just sitting around, gathering interest which can never actually be touched for all eternity.
That was as of 2021. With the massive growth of ACA enrollment since then, it could be well over $500 million by now.
HHS is basically saying that they don’t trust state insurance commissioners to enforce the “$1/mo abortion rider” provision, so they want to do it themselves. I can’t imagine the nations insurance commissioners are going to take that very well, even Republican ones, but we’ll see (then again, many Republican states don’t legally allow insurance carriers to provide abortion coverage on the individual market anyway).
“Quality Improvement Strategy (QIS)”
CMS proposes to require QHP issuers to submit QISs addressing any two of the five topic areas listed in section 1311(g)(1) of the ACA, without mandating which specific topics a QHP issuer must address to meet the QIS statutory certification requirement beginning with PY 2027.
QHP issuers would no longer be required to submit a QIS that addresses health and health care disparities as a specific topic area within their QIS, which would allow issuers to target quality efforts to the most pressing health outcome needs of their own enrollees and potentially yield more meaningful quality improvements. This change does not impact publicly reported quality ratings.
Basically, the Trump regime will no longer require insurance carriers to report on health disparities.
And what are “health disparities?”
Health disparities are largely preventable health differences that adversely affect populations who experience greater challenges to optimal health and are closely linked with intergenerational social, economic, and/or environmental factors—primarily observed among racial and/or ethnic minority populations and/or low socioeconomic status (SES) groups.
Ah, yes, that pretty much speaks for itself.
“Additional CSR Data in Rate Filings”
CMS proposes to require issuers that load rates to account for unreimbursed CSRs for the applicable rating year to submit certain information related to CSR loading in the Unified Rate Review Template and the Actuarial Memorandum for each year in which CSRs are not funded beginning with PY 2027 rate filings.
🚨 DANGER, WILL ROBINSON.
This is almost certainly the Trump regime’s precursor to attempting to eventually ELIMINATE SILVER LOADING, a pricing strategy which has resulted in millions of ACA enrollees saving thousands of dollars per year on higher-quality, more comprehensive healthcare policies every year since 2018.
HHS/CMS isn’t actually banning Silver Loading next year, but they are proposing dumping a ton of additional reporting red tape onto insurance carriers to determine whether the way CSR loading is being done is making premium tax credits “overly generous” in their view.
In other words, it would force insurance carriers into a lot more red tape & busywork, which would cost a fortune. How much? According to Katie Keith at Health Affairs, it would cost insurance carriers a whopping $630 MILLION next year alone and an additional $210 million per year after that just to file the paperwork for what insurance carriers have already been doing for 8 years now.
The insurance carriers obviously don’t want to eat those costs, so of course they’ll bump up their premiums to cover it. If you assume an average of, say, ~19 million effectuated exchange enrollees per year, that’s an extra $33 per enrollee in 2027 and an extra $11 per enrollee each year after that.
Ironically, since most ACA enrollees still receive some federal subsidies, that means the tax credits will increase by nearly the same amount to cover the extra $33/$11 per year ... meaning ultimately, it’ll be the taxpayers footing the bill for this additional red tape.
Of course, the ultimate goal of all of this is pretty clearly to reinstate CSR reimbursement payments (which would kill Silver Loading) anyway, which would end this paper chase expense ... while also jacking up net premiums even more for millions of ACA enrollees.
“Expansion of Hardship Exemption Eligibility”
The short version of this is that the Trump regime wants to expand Catastrophic plan eligibility to any ACA exchange enrollees who earn less than 100% FPL (since they aren’t eligible for tax credits) or more than 250% FPL (since they aren’t eligible for Cost Sharing Reduction assistance).
This is something which the Trump regime already put into place temporarily last fall. I wrote about it at the time:
As my colleague Louise Norris explains:
Catastrophic plans are only available to certain applicants, have deductibles equal to the maximum annual out-of-pocket limit, and enrollees must pay at least part of the cost of up to three primary care visits before the deductible is met. ... In addition, an enrollee in a catastrophic plan is not eligible to have premium subsidies paid on their behalf.
And for the purposes of the ACA’s risk adjustment program, catastrophic plans are in a separate risk pool from the metal-level plans.
... Catastrophic plans cover all of the essential benefits defined by the ACA, but with very high deductibles, equal to the annual limit on out-of-pocket costs under the ACA ... $10,600 in 2026 (for an individual).
Until now there’ve been very few Catastrophic Plan enrollees ... just 54,000 or so in 2025 out of over 24 million nationally, for several reasons: You have to be under 30 years old or qualify for a very limited range of hardship exemptions, etc.
Expanding Catastrophic eligibility isn’t necessarily a terrible idea in & of itself, but it’s one more way of pushing people towards the less-comprehensive plans with higher out-of-pocket expenses.
As I noted in a different post last fall, for many prospective enrollees a Catastrophic plan wouldn’t even cost less than a Bronze plan:
Unfortunately, in this case, the least-expensive plan (a Bronze HMO which more than doubles the deductible from $9,000 to $21,200) would still cost $2,386/month...or over one-third of their income in premiums alone.
How about the Trump Regime’s new opening of the floodgates on Catastrophic plan eligibility?
... They’ll both be 64 next year, and assuming the Age Band multiplier for Catastrophic plans is the same as it is for other individual market plans in Georgia, you’d have to multiply those prices by 2.68, which would put the cost of a Catastrophic plan for this couple at $2,286 or $2,565/month ... basically the same as a Bronze plan anyway.
I also noted recently that Trumps Council of Economic Advisors appear to have their heads up their asses, as they somehow thought that Catastrophic enrollment would explode from 54,000 in 2025 to 3 MILLION in 2026 based purely on this policy change alone (more than 55 times as many enrollees).
In fact, the early data available from the 2026 Open Enrollment Period suggests that Catastrophic enrollment has doubled or so at most to ~120,000 or so, or perhaps 4% of what they predicted would happen.
“Further Align Affordability and Coverage Incentives between Catastrophic and Metal Level Health Plans”
CMS proposes standards under which catastrophic plans may have terms of multiple consecutive years of up to 10 years and seeks comment on whether to issue similar standards for metal-level plans. Related to that proposal, CMS proposes to allow issuers to make plan-level adjustments to the index rate for such catastrophic plans, and to allow issuers of such plans to apply the applicable cost-sharing for each plan year in the contract, prorated monthly.
So, multi-year catastrophic plans would be permitted to utilize value-based insurance designs to cover preventive services over and above those that currently must be covered under certain recommendations and guidelines, before an enrollee satisfies their deductible or hits their out-of-pocked maximum. Additionally, to address an issue that has arisen in the implementation of section 1302(c) through (e) of the ACA, CMS proposes to change the permissible cost-sharing parameters for bronze plans and to update cost-sharing requirements for catastrophic plans, beginning in PY 2027.
🚨 DANGER, WILL ROBINSON.
HHS would clear the way for insurers to offer bronze and catastrophic plans with MOOPs that exceed statutory limits. As proposed, some bronze plans could have a MOOP that exceeds the statutory limit, and catastrophic plans would cover no benefits until a consumer reached 130 percent of the MOOP. These higher MOOPs would become an option beginning in 2027 and expose consumers that enrolled in these plans to extremely high out-of-pocket costs.
... Insurers that offer at least one bronze plan that satisfies the ACA’s actuarial and cost-sharing requirements (a MOOP-compliant plan) could additionally offer a bronze plan that exceeds the MOOP if doing so is needed to achieve the actuarial value of a standard bronze plan (a MOOP-noncompliant plan).
... HHS would require catastrophic plans to have an even higher MOOP. Beginning in 2027, catastrophic plans could not cover care (other than preventive services or three primary care visits) until after out-of-pocket expenses reached $15,600 for an individual and $27,600 for a family, rounded down to the lowest $50 increment.
CATASTROPHIC PLANS WOULD COVER NOTHING OTHER THAN 3 PRIMARY CARE VISITS & PREVENTATIVE SERVICES UNTIL YOUR OUT OF POCKET EXPENSES HIT $15,600 FOR ONE PERSON OR $27,600 FOR A FAMILY.
This is essentially The Onion’s classic “Infinite Deductible Plan” from 2015 in real life:
ROCHESTER, N.Y.—During a meeting with new hires Wednesday to discuss employee benefits, Radian Analytics human resources manager Ellen Schultz is said to have strongly pushed the company’s infinite-deductible health care option.
According to sources in attendance, Schultz described the low-premium, infinite-deductible plan as the simplest and most convenient choice available to employees, and said it works the same whether plan members need to visit their primary care physician, fill a prescription, or be admitted to a hospital, allowing them in each case to pay 100 percent of the incurred medical expenses.
In addition, Trump’s HHS wants to let carriers offer multi-year catastrophic plans for up to ten years ... which I guess would mean you’d have the option of having to pay $156,000 before your insurance covers anything, but hey, after that they’d cover everything (or something?). Alternately, they want to let insurers go the other way and divide your deductible up into monthly chunks of $1,300 apiece ... I think.
Apparently Trump’s CMS even wants to let insurance carriers very the out of pocket maximum BY DISEASE, which would be truly batshit insane and would be yet another step in essentially destroying the entire point of the Patient Protection & Affordable Care Act: That you never know what sort of healthcare expenses you’re going to need from day to day much less year to year, as Keith notes:
Of particular note, HHS asks whether insurers should be able to change any terms of coverage during a multi-year term and expressly acknowledges the “potential interactions” between this proposal and the ACA’s market reforms and consumer protections—including guaranteed issue, age rating, and uniform modifications to coverage.
AGAIN: You can submit public comments on any or all of these proposed changes (using this form) through March 13th.
And with that, I’ll see you again in two weeks!
Why America tolerates this healthcare mumbo jumbo instead of insisting on a comprehensive and universal plan, and why we don’t demand action and punish legislators who refuse to insist on one..is beyond me. Every other civilized nation has accomplished this, US voters can too. Enough is enough.
Universal healthcare-eliminate the BS.