Shutdown deals could decide Medicaid and ACA subsidy changes after the midterms, policy panel says

“I think we're headed toward some real legislative give-and-take at least once a year when we have the government shutdown drama,” Robert E. Andrews said during a roundtable hosted by Chief Healthcare Executive.

Andrews, CEO of the Health Transformation Alliance, a cooperative of more than 80 large self-insured employers, represented part of New Jersey in the U.S. House for 24 years. He expects Democrats to win the House in the Nov. 3 midterm elections with between 225 and 240 seats. The Senate, he said, is closer to a coin flip.

With Trump in the White House for two more years, Andrews expects any major health care legislation to come together around the Sept. 30 end of the federal fiscal year or a debt ceiling extension, when funding standoffs force negotiations.

Lisa Kidder Hrobsky, senior vice president of federal relations, advocacy and political affairs at the American Hospital Association, said the coming year will turn on those deadlines.

“I think that all of next year we are going to be waiting to see is it the debt limit, is it a shutdown that brings folks together,” she said.

Danielle Turnipseed, chief public policy officer at the Association of American Medical Colleges (AAMC), also joined the panel, which was moderated by Chief Healthcare Executive lead editor Ron Southwick.

Medicaid and marketplace coverage

“This time the Democrats will have more negotiating leverage,” Andrews said. “Being the minority party, they advocated for renewal of the ACA subsidies and a rollback of the Medicaid cuts. But being in the majority in the House, they'll have more leverage.”

Those two priorities, subsidies under the Patient Protection and Affordable Care Act (ACA) and the Medicaid cuts in H.R. 1, the 2025 budget reconciliation law, are where Andrews sees the most room for movement. He said Democratic leaders will have to choose which one to push hardest.

“I do think it will be up to the Democratic leadership, in whichever house or houses they have the majority, to make that prioritization decision,” he said.

If Democrats focus on the ACA, Andrews said, perhaps half of the Biden-era subsidy levels could return. If they focus on Medicaid, the program's work requirements could be dropped and more money could go back into Medicaid.

A larger deal is possible, he said. Trump could conceivably agree to roll back all of the H.R. 1 Medicaid cuts if he got something of great importance to him in return, such as an extension of tariffs or a permanent capital gains tax cut.

“It is more likely, though, that there will be incremental changes,” Andrews said.

“Medicare, we hear about often. Medicaid, we hear access to care,” Turnipseed said. “Let's see how those preferences of the people play out state by state, and what that means for the entire country.”

Regulation and the courts

“A huge percentage of the action will be in the executive branch through regulation, executive order and so on and so forth,” Andrews said. He expects that to intensify, with much of it winding up in the courts.

“I think you're also going to see a lot of accountability work from them, where they're looking to do oversight to see how things may have been done in the past two years,” Kidder Hrobsky said of a Democratic House.

Price transparency and PBMs

Andrews named price transparency and pharmacy benefit manager (PBM) reform as two areas with support from both parties. He pointed to a recent move by the Centers for Medicare & Medicaid Services toward requiring PBMs to disclose all of their revenue sources, which he said Democrats largely back.

He also said hospital price transparency requirements could be strengthened, an area he acknowledged hospitals may see as making compliance more difficult.

Kidder Hrobsky said the American Hospital Association is tracking whether transparency legislation gains momentum. “I think we would all like some type of bill to be able to pass so we can make certain that patients have the information they need,” she said.

Appropriations look steadier

Even with the administration requesting lower funding levels for some programs, Kidder Hrobsky said annual appropriations look relatively safe.

“There really is a lot of bipartisan support for funding in some of the programs,” she said.

Turnipseed called the appropriations process “probably the strongest, best lever that we have” for bringing both parties together, particularly on medical research. The National Institutes of Health fully obligated its grant funding in fiscal years 2025 and 2026, according to an AAMC analysis she cited, but awarded fewer grants in fiscal 2026 than in fiscal 2024. Grant money held back and then released aggressively near the end of the fiscal year created disruption for research institutions, she said.