The massive House reconciliation bill was about more than Medicaid cuts and Trump tax cuts. It would also take steps to significantly roll back the Affordable Care Act.

Why it matters: Although much of the attention has been on the Medicaid provisions of the bill, the final House draft called for an overhaul of ACA marketplaces that would result in coverage losses and savings for the government.

Driving the news: Many of the changes erect barriers to enrollment that supporters say are aimed at fighting fraud.

• Brian Blase, president of Paragon Health Institute and a health official in Trump's first administration, said Republicans are not trying to repeal the ACA but rather roll back Biden-era expansions "that have led to massive fraud and inefficiency."
• The CBO estimates the ACA marketplace-related provisions would lead to about 3 million more uninsured people.
• Cynthia Cox, a vice president at KFF, said the changes "sound very technical," but that taken together, "the implications are that it will be much harder for people to sign up for ACA marketplace plans."

What's inside: The bill would end automatic reenrollment in ACA plans for people getting subsidies, instead requiring them to proactively reenroll and resubmit information on their incomes for verification.

• It would also prevent enrollees from provisionally receiving ACA subsidies in instances where extra eligibility checks are needed, which can take months.
• Some legal immigrants would also be cut off from ACA subsidies, including people granted asylum and those in their five-year waiting period to be eligible for Medicaid.

What they're saying: In a letter to Congress, patient groups pointed to the various barriers as "unprecedented and onerous requirements to access health coverage" that would have "a devastating impact on people's ability to access and afford private insurance coverage."

Between the lines: A last-minute addition to the bill would also fund cost-sharing reduction (CSR) payments to insurers.

• The effect of this change would actually be to reduce the subsidies that help people afford premiums, and save the government money, by reducing the benchmark silver premiums used to set the subsidy amounts.
• Democrats worry that if Congress also allows enhanced ACA subsidies to expire at the end of this year, the combined effect with the CSR change would be even higher premium increases for enrollees next year.
• Insurers are also worried that they are already planning their premium rates for next year, and funding CSRs is throwing in a late curveball.

The big picture: Blase said changes like ending automatic reenrollment are needed to increase checks that ensure people are not claiming higher subsidies than they're entitled to.

• Cox said another way to address fraud would be to target shady insurance brokers rather than enrollees themselves. She estimated marketplace enrollment could fall by roughly one third from all the changes together.

Go deeper

By increasing the deficit by at least $2.3 trillion, the House reconciliation bill would prompt automatic Medicare cuts under sequestration, according to a CBO analysis prepared for House Budget Committee Ranking Member Brendan Boyle.

Why it matters: Medicare isn't exempt from PAYGO cuts and would sustain a 4% reduction in spending, which translates to almost $500 billion over 10 years, unless Congress steps in.

By the numbers: The reduction to Medicare spending under PAYGO is limited to 4%, or an estimated $45 billion for FY26, according to CBO.

• Those Medicare cuts could continue to increase in the succeeding years, to about $75 billion in 2034, and total about $490 billion from 2027 to 2034.

Yes, but: Cuts to Medicare through PAYGO have never been allowed to take effect, because Congress has either excluded those effects from the "scorecard" as part of the underlying legislation or later acted to delay or otherwise mitigate the effects, KFF noted last week.

• That includes during the passage of the Tax Cuts and Jobs Act of 2017 and the American Rescue Plan in 2021, both of which increased the deficit.
• Even if the sequester is waived, the cuts could provide a talking point as the Trump administration looks for ways to cut spending, with discretionary programs being likely targets, said Joe Antos, senior fellow emeritus at the American Enterprise Institute.

The bottom line: Excluding the legislation from PAYGO requirements requires 60 votes in the Senate.

• That could be a tough lift, especially if Democrats aren't inclined to help with the budget math.

1. COVID shots: The CDC is no longer recommending COVID-19 shots for healthy kids and healthy pregnant women, HHS Secretary Robert F. Kennedy Jr. announced today. More here.
2. Drug pricing: President Trump's "most favored nation" drug pricing plan is less enforceable without the involvement of Congress, Caitlin Owens reports.
3. Unpublicized outbreak: The public wasn't notified after federal agencies investigated an E.coli outbreak that sickened 80 people, KFF Health News reports in the WaPo.
4. Weight-loss drugs: The percentage of adult patients prescribed a GLP-1 drug increased more than 350% from 2019 to 2024, with Ozempic showing the sharpest rise, a FAIR Health analysis of more than 51 billion insurance claims shows.

1. Reconciliation's effects: CBO issued preliminary estimates of the House reconciliation bill's effects on revenues and spending to households and the effects of states' responses to changes to Medicaid and SNAP.
2. HHS savings: The department's inspector general released a summary document identifying about $50 billion in potential savings through recovery payments and improvements to health programs.
3. More savings: GAO recommended actions that Congress could take that would save tens of billions, including site-neutral payment policies that could save Medicare $157 billion over a decade.