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There have been many stories since the November 5 election about potential health care changes in 2025. People are asking, “What can we expect as far as Affordable Care Act (ACA) changes and continuation of ACA subsidies?” “Will Pharmacy Benefit Managers (PBMs) face continuing scrutiny?” “Could we see a future national abortion ban from the new Trump administration?” “Will Congress enact new limits on employers’ deductibility of health benefits for employees?”
 
Let’s look at these issues and what to expect concerning health insurance in 2025.

Affordable Care Act (ACA)

Changes for the ACA are inevitable. It is a matter of how much – and how soon. One factor could be when potential cabinet nominees can secure congressional approval. Another is how soon they begin to push for changes. 
 
Issue 1: Maintaining the law or working to change it. During his first term, President Trump tried repeatedly to repeal the ACA. Efforts fell short then, and it’s uncertain how much enthusiasm there is for repeal now. It has been mentioned as a priority by a few members of Congress set to return in 2025. Tweaks are seen as more likely than an overhaul. Many of Trump’s 2024 voters get health coverage through the state and federal marketplaces.
 
Issue 2: Extending the ACA subsidies. The Biden administration increased ACA subsidies as part of the Inflation Reduction Act (IRA) in 2022. That helped make coverage more affordable for marketplace participants. Those increased subsidies will end in late 2025 without a renewal by Congress. If the subsidies end, the Urban Institute says the country’s uninsured rate would increase by 16%. ACA marketplace coverage would decline 42% – and rates will jump dramatically. More than seven million Americans would no longer have access to subsidized plans. The Congressional Budget Office says premiums in 2026 would double or increase even more in some areas.
 
Issue 3: Will Congress change the formula for Medicaid funding? Republicans could advocate for a change in the formula for funding Medicaid. That’s the joint federal-state government program for lower-income and disabled persons. Analysts say states that have not expanded Medicaid would account for more than sixty percent of the enrollment drop in ACA exchange coverage. Many enrollees are represented by Republicans in Congress. That could prompt some to oppose a lapse in the subsidies.
 
President Trump could also bypass Congress. He could encourage the Department of Health and Human Services (HHS) to approve state waiver requests in how their Medicaid programs operate.
 
If the new Trump administration does not defend the ACA against legal challenges, that could undermine the ACA further. That includes rolling back the current requirement to cover preventive care at no cost.
 
We’ll report further as the year unfolds

New Pharmacy Benefit Manager (PBM) Restraints

Earlier this month, Sens. Elizabth Warren, D – Mass, and Josh Hawley, R – Mo., introduced a U.S. Senate bill to mandate health care companies that own PBMs or health insurers sell pharmacy assets within three years. Similar legislation has also been introduced in the U.S. House of Representatives. This required break up would dramatically shake up the pharmacy supply chain. It would reduce revenue for some chain pharmacies and benefit independents that complain PBMs pay them less.
 
President-elect Donald Trump said on December 16 that he plans reduce the influence of PBM middlemen. The result was stock price drops of as much as 4.3% for CVS Health Corp., and a 3.9% drop for UnitedHealth Group. Cigna also declined by as much as 2.6% after Trump’s remarks. Losses continued the next day after Pfizer CEO Albert Bourla said President-elect Trump is “very committed” to PBM reform.

Possible Cap for Employers on Health Tax Exclusion

In the final days of 2024 and the Biden administration, Congress is considering changes to the employer health tax exclusion on employee benefits.
 
The Fair Care Act of 2024 establishes a limit for employers on the amounts spent on employer-sponsored health care. The bill would exclude $10,200 in spending for employee-only coverage and $27,500 for family coverage from an employee’s taxable income. It is estimated the proposed limit could add $709 billion in tax revenue over 10 years.
 
According to an analysis by KFF, the former Kaiser Family Foundation, the average annual premium for single coverage in 2024 was $8,951. At smaller firms, the average for single coverage was $9,131. For family coverage, the average premium in 2024 was $25,572; at smaller firms, it was $25,719. The average single coverage premium was up 6% in 2024, while the average family coverage premium was up 7% in 2024.
 
If the measure does not pass in the current Congress, it could come back for consideration by the 119^th Congress, which convenes in January.

Concern Over a National Abortion Ban

California law considers abortion basic health care. Abortion is legal in the state until fetal viability. A pregnancy is viable when a doctor determines the fetus could live outside the uterus without extreme medical measures. Abortion is also legal if a physician certifies the pregnancy poses a risk to the pregnant person’s life or health.
 
In Nevada, abortion is legal for any reason up to 24 weeks into a pregnancy.
 
According to the California Surgeon General, California has implemented a host of measures to safeguard that abortion remains legal. It wants to ensure abortion is accessible to residents and those traveling to California from states where abortion access is restricted.
 
President-elect Trump has said that he will not sign a federal abortion ban. However, there are medical experts who believe a new Trump administration could restrict abortion nationwide without explicitly banning it.
 
If approved by the 119^th Congress, a national abortion measure would override California, Nevada, and other states’ protections. However, passage is uncertain. Some Republican senators may be reluctant to support a nationwide ban. Polling in 2024 showed 63% of Americans believe abortion should be legal in all or most cases.
 
Other paths to a national prohibition include FDA action to restrict mifepristone, a medication used to bring about a medical abortion. The Justice Department (under Attorney General Pam Bondi) could also decide to not defend access to the abortion pill. A third option might be to enforce an 1873 law. The Comstock Act prohibits the mailing of materials designed or intended to result in an abortion.
 
President-elect Trump told Time magazine this month that he will ensure the Food and Drug Administration will not block access to abortion medications. Abortion advocates are skeptical.
 
Robert F. Kennedy Jr., Trump’s nominee for the U.S. Department of Health and Human Services (HHS), has said he supports legal abortion access until viability. That could mean a potential faceoff with GOP hardliners. On December 17, Sen Tommy Tuberville (R – Ala.) told The Washington Poist that Kennedy and President-elect Trump have agreed that abortion should be left to the states to decide. Again, this is an area that we will continue to watch.