Last-minute House Reconciliation Provision Would Set Up Clash with States over Marketplace Abortion Coverage

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The House of Representatives approved a version of the reconciliation bill that included a last-minute provision that would bar ACA Marketplace plans that include abortion coverage from receiving newly-appropriated federal payments related to cost-sharing reductions (CSRs). This provision would have a major impact on Marketplace plans in the 12 states that require all plans to include abortion coverage and would also impact some plans in 13 other states and DC that allow marketplace plans to include abortion coverage (Figure 1). In 2023, approximately 3.7 million people were enrolled in ACA marketplace plans in the 12 states that require abortion coverage, and 36% (1.3 million) of them had lower deductibles and copays as a result of the CSRs.

The ACA requires silver Marketplace plans to provide lower patient cost-sharing to enrollees with incomes between 100% FPL and 250% FPL. For a family of three, 100% FPL is equal to $26,650 annually and 250% FPL is equal to $66,625. In 2024, on average, deductibles in silver plans were approximately $5,000 without CSRs, but for those at the lowest end of the income scale, CSRs reduced deductibles to about $90. Silver Marketplace plans originally received payments from the federal government to offset the added cost of the reduced cost-sharing for enrollees with low incomes. However, the first Trump administration ended those payments, and insurers compensated by increasing silver premiums (often called “silver loading”).

The House-passed budget reconciliation bill appropriates funding to once again pay insurers for CSRs, but prohibits Marketplace plans that include coverage for abortion from obtaining CSRs. This provision creates a clash between federal and state laws. Insurers in 12 states that require abortion coverage would not be able to access federal funding for reduced cost-sharing under the House provision. How this would get resolved, and what would happen to abortion coverage for low-income ACA enrollees in these states, is unclear.