Changes to Medicaid, ACA Marketplace and SNAP signed into law: What kidney patients should know

On July 4, the President signed into law H.R. 1, the budget reconciliation bill from congressional Republicans (aka the "One Big Beautiful Bill" Act). The legislation includes significant changes to Medicaid, the Affordable Care Act (ACA) marketplaces, and the Supplemental Nutrition Assistance Program (SNAP). The nonpartisan Congressional Budget Office (CBO) has estimated that over the next 10 years, the new law will result in 10 million people becoming uninsured, cut federal Medicaid funding by $990 billion, cut federal ACA marketplace funding by $213 billion and cut federal SNAP funding by $280 billion. The funding cuts to Medicaid and SNAP are the largest ever cuts to the nation's safety net. 

The impact of H.R. 1 on people living with or at risk for kidney disease will be considerable considering that Medicaid is a vital part of the nation's safety net for people with low incomes and millions of people with and at-risk for kidney disease rely on Medicaid for their health care. Losing health coverage means people will lose access to health care providers, services and treatments that can prevent chronic kidney disease (CKD), diagnose CKD earlier and slow its progression, and manage CKD and any comorbidities. Forty-five percent of dialysis patients are dually eligible for Medicare and Medicaid coverage; there are different levels of Medicaid wrap-around coverage for dually eligible beneficiaries, depending on a person's income. 

Studies have shown that states that expanded Medicaid have better patient outcomes. Specifically:

• Diabetes and high blood pressure are responsible or greatly contribute to two out of three new cases of kidney failure. People who live in states that expanded Medicaid had improved blood pressure and blood glucose levels compared to those states that did not expand.
• Access to Medicaid resulted in lower mortality rates in the first year among people who started dialysis compared to those in states that did not expand Medicaid.
• More patients in states with Medicaid expansion were preemptively placed on the transplant list so they could be on dialysis for a shorter time.

The following is a summary of the Medicaid, ACA, and SNAP provisions in the new law: 

Medicaid

• Requires states to implement 80-hour a month work reporting requirements for all Medicaid expansion individuals ages 19-64, with some exceptions. (Effective no later than Dec. 31, 2028)
• New limits on provider taxes and reduces the safe harbor threshold for states that have expanded Medicaid. (Effective upon enactment, but states may have up to 3 fiscal years to transition existing arrangements that do not comply).
• There is no language that specifically excludes dialysis patients.
• Limits the use of state-directed payments to finance the state's share of the Medicaid program. (Effective upon enactment)
• Establishes a $50 billion rural health grant program for states between fiscal years 2026 and 2030 to be used for payments to rural health facilities. (Effective upon enactment but funding is first available Jan. 1, 2026)
• Requires states to impose cost sharing of up to $35 per service on expansion adults with incomes 100-138% of the federal poverty level (FPL). It exempts primary care, mental health and substance use disorder services, as well as services provided by federally qualified health centers, behavioral health clinics and rural health clinics. (Effective Oct. 1, 2028)
• Requires states to conduct eligibility redeterminations at least every 6 months for Medicaid expansion adults. (Effective for renewals scheduled on or after Dec. 31, 2026)
• Limits retroactive coverage in Medicaid from three months for all enrollees to one month for Medicaid expansion enrollees and two months for traditional Medicaid enrollees. (Effective Jan. 1, 2027)
• Requires states to obtain contact information on all Medicaid enrollees and to review the Master Death File at least quarterly to determine if any enrolled individuals are deceased. (Effective Jan. 1, 2027)
• Eliminates the temporary financial incentive that was created in the American Rescue Plan Act of 2021 for non-expansion states to expand Medicaid, which would give them a 2-year, 5% increase to their federal matching funds for their traditional Medicaid population. (Effective Jan. 1, 2026)
• Prohibits the Secretary of HHS from implementing, administering or enforcing certain provisions from the CMS Eligibility and Enrollment final rule until Oct. 1, 2034. This rule would have streamlined the Medicaid application process to make it easier for people to enroll in and retain Medicaid and CHIP coverage. (Effective upon enactment)
• Restricts Medicaid or CHIP eligibility to U.S. citizens and nationals, lawful permanent residents, certain Cuban and Haitian immigrants, citizens of the Freely Associated States lawfully residing in the U.S., except that CHIP funding may still be used for expenditures for health services initiatives under the plan for improving the health of children. (Effective Oct. 1, 2026)
  • The bill excludes many other lawfully present individuals from Medicaid eligibility, including individuals granted asylum as well as those admitted as refugees and survivors of trafficking, domestic violence and other serious crimes.
• Requires HHS to reduce federal financial participation to states for identified improper payment errors related to payments made for ineligible individuals and overpayments made for eligible individuals, and where insufficient information is available to confirm eligibility. (Effective FY 2030)

ACA marketplaces

• Ends auto-renewals and requires information verification by the marketplace before coverage to receive premium tax credits or cost-sharing reduction (CSR) payments. If a marketplace does not have a process for pre-enrollment verification, enrollees will be ineligible for premium tax credits or CSR payments. (Effective for taxable years after Dec. 31, 2027)
• Prohibits any consumer who enrolls in a plan via a non-qualifying life event (QLE) special enrollment period (SEP) from receiving subsidized coverage in the form of premium tax credits or CSR payments. (Effective plan years beginning after Dec. 31, 2025)
• Individuals otherwise eligible for Medicaid but denied coverage due to work reporting requirements will also be ineligible for ACA premium tax credits. (Effective Jan. 1, 2027)
• Requires that all premium tax credit recipients repay the full amount of any excess, eliminating repayment limits for low-income individuals (household income less than 400% of the FPL). (Effective for taxable years after Dec. 31, 2025)
• Limits eligibility for subsidized ACA Marketplace coverage to U.S. citizens and nationals, lawful permanent residents, Compact of Free Association migrants and certain immigrants from Cuba and Haiti. (Effective Jan. 1, 2027)
  • The bill excludes many other lawfully present individuals from eligibility for subsidized ACA coverage, including individuals granted asylum as well as those admitted as refugees and survivors of trafficking, domestic violence and other serious crimes.
• Eliminates the rule allowing individuals earning less than 100% of the FPL to receive ACA Marketplace subsidies if they are ineligible for Medicaid due to immigration status. (Effective for taxable years after Dec. 31, 2025)

SNAP

• For the first time in SNAP's history, states will be required to contribute toward the cost of SNAP food benefits, not just administrative costs. The required match would be tied to each state's SNAP payment error rate. (Effective FY 2028)
• Federal support for administrative costs would drop from 50% to 25%. (Effective FY 2027)
• Expands work requirements/time limits (participants must prove that they work at least 20 hours a week; if not, they can only receive SNAP for three months in three years). Effective upon passage:
  • Raises the age for Able-Bodied Adults Without Dependents (ABAWDs) subject to work requirements from 54 to 64.
  • Narrows the definition of a dependent child from those under 18 to those under 14.
  • Limits caregiving exemptions.
  • Removes current exemptions for veterans, individuals experiencing homelessness and youth aging out of foster care.
• Maintains SNAP eligibility for U.S. citizens, nationals, certain lawful permanent residents, and Cuban and Haitian nationals, but excludes many legal immigrants with humanitarian protections. (Effective upon passage)

Michael Ly is the director of public policy at the American Kidney Fund