How the 2025 Budget Bill Reshapes the ACA: What You Need to Know

Examining the Implications of Medicaid Work Requirements, Enrollment Changes, and Tax Credit Expirations

On May 22, 2025, the U.S. House of Representatives narrowly passed the One Big Beautiful Bill Act, a comprehensive budget reconciliation package that proposes significant alterations to the Affordable Care Act (ACA) and Medicaid programs. The bill introduces Medicaid work requirements for certain adult populations, shortens the ACA open enrollment period, and allows enhanced premium tax credits to expire, potentially impacting millions of Americans’ healthcare access and financial well-being.

Medicaid Work Requirements

The bill mandates that adults under 65 without dependents or disabilities must work, study, or volunteer at least 80 hours per month to qualify for Medicaid coverage. These requirements are set to take effect in December 2026, moving up the timeline from previous federal guidance. According to the Congressional Budget Office (CBO), such changes could result in approximately 8.6 million individuals losing Medicaid coverage.

A KFF policy analysis notes that prior attempts at implementing work requirements in states like Arkansas led to over 18,000 people losing coverage in less than a year, many due to paperwork barriers rather than non-compliance.

Shortened ACA Open Enrollment Period

The legislation also proposes reducing the ACA open enrollment period from its current 75-day window to as few as 30 days. Such a move may disproportionately affect lower-income populations, who often require more time and support to evaluate health plans.

The Center on Budget and Policy Priorities has previously warned that shortening enrollment timelines could cause millions to miss coverage opportunities. According to Fierce Healthcare, one-third of ACA enrollees could lose access due to these changes.

Expiration of Enhanced Premium Tax Credits

Enhanced premium tax credits—originally expanded under the American Rescue Plan Act and extended by the Inflation Reduction Act—are slated to expire at the end of 2025. These subsidies currently reduce out-of-pocket premiums for over 13 million people.

If allowed to expire, the CBO projects a resulting increase of 4.2 million in the uninsured population by 2034. According to the Commonwealth Fund, premiums could rise by as much as 53% for some households.

Projected Increase in Uninsured Rates

Taken together, the Medicaid work requirement, shortened enrollment windows, and rollback of premium subsidies are expected to drive a significant increase in the number of uninsured Americans. A detailed analysis by the Kaiser Family Foundation (KFF) estimates that 13.7 million people could lose their coverage by 2034 if all proposed changes go into effect.

Healthcare advocacy group Protect Our Care describes the bill as a “quiet dismantling” of ACA achievements, particularly in expanding access to care and reducing racial and economic disparities in insurance coverage.

The 2025 budget reconciliation bill marks a significant shift in healthcare policy, with potential consequences for coverage, affordability, and health equity. If passed by the Senate and signed into law, these changes could reshape the ACA and Medicaid for years to come. Stakeholders—from patients to providers to insurers—will need to adapt to a more restrictive and less subsidized healthcare environment.

Medical Disclaimer

The information provided in this article is for educational and informational purposes only and is not intended as medical advice. It should not be used to diagnose, treat, cure, or prevent any medical or mental health condition. Always seek the guidance of a qualified healthcare professional or licensed mental health provider with any questions you may have regarding a medical condition, diagnosis, or treatment. Never disregard professional medical advice or delay seeking it because of something you have read here.