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From the passage of a massive bill that reduced federal funds for Medicaid to a comprehensive overhaul of a federal vaccine advisory panel, Congress and the Trump administration delivered major changes to America’s public health system in 2025.
Many of those changes are poised to reshape coverage, care delivery and public health policy in the new year as provisions take effect, healthcare premiums more than double, and new requirements begin to kick in.
Here’s a look at the biggest policy shifts set in motion last year that should be felt in the new year:
ACA Subsidies Will Sunset
Premium tax credits meant to further reduce the price of healthcare plans bought on the Affordable Care Act marketplace expired on Dec. 31 after Congress declined to address a looming “subsidy cliff.”
The credits increased financial assistance and expanded it to those with incomes above 400% of the federal poverty lines. Since the credits were first introduced in 2021, enrollment in the ACA marketplace increased to more than 24 million.
The Center on Budget and Policy Priorities projected that almost 22 million people would see their healthcare costs “dramatically rise” or would lose their coverage altogether without the extension. The Urban Institute estimated that 7.3 million fewer Americans would receive subsidized coverage in 2026 and that 4.8 million more would be uninsured in 2026.
State Medicaid Expansion Incentives to End
The American Rescue Plan Act of 2021 offered a temporary financial incentive to encourage states to expand Medicaid coverage to more low-income Americans. The act used the 138% poverty level listed in the Affordable Care Act to offer states a two-year, 5% match to the Federal Medical Assistance Percentage, the amount the federal government shoulders, for Medicaid expansion expenditures.
But the incentive will largely end as it currently exists due to the legislation known as the “big, beautiful bill.” States wishing to qualify for the enhanced funding must have completely expanded their Medicaid programs by Jan. 1. States that have already expanded their programs will retain their existing FMAP levels, and those receiving the two-year bonus will continue to receive it until the period ends.
Removal of Tax Liability Caps
For ACA marketplace enrollees, their premium tax credits are determined based on what they estimate their income will be at the beginning of the year. If the prediction is incorrect and the income is higher than expected, they are expected to repay. The process of repayment to the IRS is known as reconciliation and was expected to be undertaken when enrollees filed their federal income tax returns.
Now, under a provision of the “big, beautiful bill,” marketplace enrollees will be expected to repay the full amount they owe. Also, the continuous special enrollment period for people whose incomes are below 150% of the federal poverty line will end. In addition, those enrolling in coverage during a special enrollment period based on their income and not tied to a qualifying life event will not be eligible for the credits beginning this year.
Change in Tax Credit Eligibility for Noncitizens
The “big, beautiful bill” also included changes to the eligibility requirements for people who are not citizens who wish to receive ACA marketplace premium credits.
Credits will be limited to green-card holders, Cuban or Haitian entrants, or Compact of Free Association migrants or citizens of the Marshall Islands, Palau or Micronesia. Previously eligible categories, like refugees, asylum-seekers and those granted temporary protected status, will no longer qualify.
The bill also ends a special rule known as the Medicaid waiting list loophole. The rule allowed people who are not citizens whose incomes are below 100% of the federal poverty line and who are ineligible for Medicaid coverage due to their status to receive the premium credits.
The changes are expected to take effect Jan. 1.
Caps on Federal Loans for Medical Students
The “big, beautiful bill” also caps the amount medical students can receive in Federal Direct Stafford Loans and Federal Direct PLUS Loans.
The changes will take effect on July 1.
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More Vaccine Reviews
The Department of Health and Human Services is expected to continue its overhaul of vaccine recommendations in the new year, starting with the schedule of recommended vaccines for children. The proposed new schedule will recommend fewer shots to mimic those from other developed countries, specifically Denmark. CNN reported that the plan has not been finalized but was expected in late December before it was pushed to 2026.In addition, the Centers for Disease Control and Prevention’s vaccine advisory panel is set to meet three times in the new year: Feb. 25-26, June 24-25 and Oct. 21-22.
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Aneeta Mathur-Ashton
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