President Donald Trump’s new administration is moving at light speed to make big changes, from downsizing the federal government to deporting immigrants who entered the country illegally. Republicans in Congress also are planning their own reforms.
Recently, Politico obtained an informal document circulated among Republicans in Congress that lists changes they are considering now that Republicans control Congress and the White House.
Some of those changes would affect health care, including Medicare and Affordable Care Act coverage. For now, they are talking points, but they could become federal legislation soon.
Here are several ways Republicans might soon transform health care as we know it — along with their estimates for how much money each change would save or cost the federal government.
Eliminate Medicare coverage of bad debt
Estimated effect of this proposal on the federal government: Up to $42 billion in savings over 10 years
Medicare is the federal health insurance program that serves people who are aged 65 or older or have disabilities or certain terminal conditions.
When a patient on Medicare fails to pay their cost-sharing obligations to a health care provider, their unpaid balance is considered “Medicare bad debt.” As a program, Medicare reimburses providers for a portion — currently up to 65% — of this debt.
This new proposal by Republicans in Congress involves “gradually reducing the amount that Medicare reimburses providers for bad debt.”
What it would mean for you: This proposal would save money for Medicare. And anything that saves Medicare money also stands to prolong its solvency. (Currently, one of Medicare’s trust funds is projected to be depleted by 2036.)
That’s good news for anyone who is or will be on Medicare — which is pretty much all of us. However, this change would mean less revenue for providers, who might then change their policies. For example, some might decide to stop accepting Medicare insurance. So, like any major legislative change, this one could have unintended consequences.
Adopt site-neutral payments by Medicare
Estimated effect of this proposal on the federal government: Up to $146 billion in savings over 10 years
The amount that the Medicare program pays to health care providers can vary depending on where the service was provided.
Payment is often higher for a service rendered at a hospital outpatient department or ambulatory (same-day) surgical center than when the same service is performed at a doctor’s office.
For example, AARP reports that in 2023, doctors and hospitals received $1,015 when a colonoscopy was performed in a outpatient department and $616 when it was performed at a surgical center. Payment dropped to $345 when a colonoscopy was performed in an office setting.
This new proposal by Republicans involves “equalizing Medicare payments for health care services that can be safely delivered in a physician’s office.”
In short, Medicare would pay the same rate for a given service regardless of where it was performed. This practice is known as site-neutral payments.
What it would mean for you: This proposal would save Medicare money, thereby improving the program’s long-term financial standing. That’s a good thing for anyone who is or will be reliant on Medicare for health insurance.
The trade-off would be less compensation for hospital outpatient departments and ambulatory surgical centers when they perform a service that can also be performed at a doctor’s office. That might prompt them to change their practices, such as by discontinuing offering such services.
Eliminate Medicare’s Inpatient Only list
Estimated effect of this proposal on the federal government: Up to $10 billion in savings over 10 years
Medicare’s Inpatient Only (IPO) list is a document that the Medicare program updates annually. It lists procedures that Medicare typically covers only if they are performed while a patient is formally admitted to a hospital, as opposed to, say, at a hospital’s outpatient department or a same-day surgery center.
This new proposal by Republicans in Congress would “eliminate the inpatient-only list so more same-day surgeries and procedures can be performed in lower cost, outpatient settings.”
What it would mean for you: People with Medicare would have more options when it comes to where certain procedures are performed, since Medicare would cover them regardless of whether they were done in inpatient or outpatient facilities.
Enact 5 bills expanding Medicare coverage
Estimated effect of this proposal on the federal government: Up to $20 billion in increased costs (across the five bills) over 10 years
Republicans also want to renew their focus on several bills that stalled over the past two years, when Democrats controlled the Senate and House. Among the health care-related bills they hope will become law are the:
- Preserving Telehealth, Hospital, and Ambulance Access Act (H.R. 8261): This bill would extend Medicare coverage of telehealth, Medicare programs that sustain rural and low-volume hospitals, and Medicare add-on payments to preserve access to emergency ambulance services.
- Nancy Gardner Sewell Medicare Multi-Cancer Early Detection (MCED) Screening Coverage Act (H.R. 2407): This bill would authorize Medicare to cover a new type of screening that can detect multiple types of cancer through a blood test once the screenings are approved by the U.S. Food and Drug Administration (FDA).
- American Medical Innovation and Investment Act (H.R. 8816): Among other things, this bill would speed the process of approving new medical technologies for Medicare coverage once the technologies come to market.
- Ensuring Patient Access to Critical Breakthrough Products Act (H.R. 1691): This bill would provide Medicare coverage for medical devices approved under the FDA’s Breakthrough Devices Program.
- Treat and Reduce Obesity Act (H.R. 4818): This bill would expand Medicare coverage of intensive behavioral therapy for obesity.
What it would mean for you: If these bills become law, Medicare would cover more products and services.
Require repayment of all excess ACA subsidies
Estimated effect of this proposal on the federal government: Up to $46 billion in savings over 10 years
Currently, people with insurance through the Affordable Care Act (ACA) who receive excess subsidies do not have to repay all of the excess if their income is less than 400% of the federal poverty level. The IRS, which collects excess subsidies at tax time when applicable, refers to this as a repayment limitation.
This Republican proposal would end repayment limitations.
What it would mean for you: Everyone who receives more ACA subsidies than their income qualifies them for would have to repay all of the excess.
Repeal the ACA rule for DACA recipients
Estimated effect of this proposal on the federal government: Up to $6 billion in savings over 10 years
An administrative rule adopted in 2024 extended Affordable Care Act insurance to DACA recipients — meaning people who are in the United States under the Deferred Action for Childhood Arrivals (DACA) policy. This policy postpones deportation for immigrants who entered the country illegally as children.
Republicans in Congress are considering revoking this rule.
What it would mean for you: DACA recipients would no longer be eligible for ACA health insurance coverage.
The future of the policy itself is unclear, though. In January, a federal appeals court ruled that the DACA policy is illegal but stopped short of saying that it should be discontinued nationwide. The appeals court is keeping its ruling on hold “pending a further order of this court or the Supreme Court.”
Otherwise limit eligibility based on citizenship status
Estimated effect of this proposal on the federal government: Up to $35 billion in savings over 10 years
Repealing the ACA rule for Deferred Action for Childhood Arrivals isn’t the only way Republicans in Congress are considering restricting eligibility for federally funded health care programs based on citizenship status.
Another policy change on their list “would remove specified categories of non-citizens from eligibility for federal health care programs,” including eligibility for ACA premium subsidies and Medicaid, the state and federal government health insurance program for people with low incomes.
What it would mean for you: The Republicans who threw out this idea didn’t specify which types of non-citizens would lose eligibility beyond noting that “many non-citizens who entered the country illegally are eligible for federal health care programs.” But it’s fair to say that if this policy became reality, at least some of those non-citizens who currently receive ACA subsidies or have Medicaid would no longer qualify for such coverage.
Repeal the ACA ‘family glitch’ rule
Estimated effect of this proposal on the federal government: Up to $35 billion in savings over 10 years
An administrative rule adopted in 2022 fixed an element of the Affordable Care Act of 2010 that prohibited some people from receiving health insurance subsidies if a family member had access to an employer-provided health plan.
Republicans in Congress say President Joe Biden’s administration “illegally altered” the Affordable Care Act, a federal law, with the rule change. So, they are considering undoing the 2022 change.
What it would mean for you: People who are eligible for employer-sponsored health insurance via a family member would be ineligible to receive ACA subsidies if they opt for ACA insurance over the employer-sponsored insurance.
Eliminate the Prevention and Public Health Fund
Estimated effect of this proposal on the federal government: Up to $15 billion in savings over 10 years
The Prevention and Public Health Fund was established under the Affordable Care Act as a way to invest in public health and boost health care quality.
In the document obtained by Politico, Republicans in Congress describe the fund as a “slush fund” for the secretary of the U.S. Department of Health and Human Services that can be spent “on any program or activity under the Public Health Service Act the Department chooses without further congressional action.” So, they are interested in eliminating the fund.
What it would mean for you: According to Republicans, this proposal “would repeal this fund but does not cut a specific program.” In that regard, it might not affect the average person, but the implications are unclear.
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