Health Care Matters | October 24
Shutdown Stalemate Puts ACA Subsidies and Coverage at Risk
Now in its fourth week, the ongoing government shutdown has stalled Congressional efforts to extend enhanced premium tax credits under the Affordable Care Act (ACA), transforming what was once an abstract policy deadline into an imminent crisis for millions of Americans ahead of open enrollment. Senate Republicans and Democrats remain deadlocked over the ACA subsidies, with Democrats refusing to vote for government funding unless the enhanced tax credits are extended, while Republicans insist they won't negotiate until the government reopens. According to Politico and The Washington Post, insurers have filed 2026 rates assuming no extension of the subsidies, with average marketplace premiums projected to rise about 18 percent nationwide and even higher in some states. If Congress fails to act soon, roughly 20 million people who rely on these enhanced tax credits could face steep premium increases or lose coverage entirely. The uncertainty comes as the shutdown's financial fallout widens, with thousands of federal workers missing their first full paycheck on Friday and household budgets already under severe strain. Read more here, here, and here.
Why It Matters
This convergence of budget gridlock and health policy uncertainty threatens to erode the coverage gains achieved since the ACA’s passage. Without timely action, younger and healthier enrollees may drop coverage, destabilizing marketplace risk pools and driving further premium increases for those who remain insured. For states, payers, and providers, the result could be higher churn, greater uncompensated care, and fewer affordable plan options for consumers. With open enrollment approaching and the shutdown now in its fourth week, the window for Congressional action is rapidly closing, leaving insurers, states, and consumers with little time to adjust. The episode underscores how closely intertwined federal funding decisions are with the stability of the health coverage landscape, and how delays in Washington can ripple through every level of the health care system.
CMS Lifts Claims Hold for Some Medicare Services, Keeps Restrictions on Telehealth and Hospital-at-Home
Following widespread confusion, provider community pushback, and significant operational disruption, CMS has instructed all Medicare Administrative Contractors (MACs) to lift the claims hold and process claims with dates of service on or after October 1, 2025, for select services impacted by expired Medicare payment provisions under the Full-Year Continuing Appropriations and Extensions Act, 2025 (Pub. L. 119-4, Mar. 15, 2025). This includes claims paid under the Medicare Physician Fee Schedule, ground ambulance transport, and Federally Qualified Health Center (FQHC) services. CMS also clarified that telehealth claims can be processed when they are definitively for behavioral or mental health services. However, MACs are instructed to continue holding claims for other telehealth services that cannot be confirmed as behavioral or mental health–related, as well as Acute Hospital Care at Home claims. Read here and here.
Why It Matters
CMS's policy reversal provides critical payment relief for providers facing cash flow disruptions during the government shutdown. However, MACs may stagger payment of claims as they work through any backlog, and while MACs typically try to pay claims within 30 days, there may be residual delays over the coming weeks. Additionally, if Congress retroactively restores the work GPCI floor of 1.0 or other expired provisions, MACs will need to reprocess affected claims which can be a costly and time-consuming process. The continued hold on non-behavioral health telehealth and hospital-at-home services leaves these innovative care delivery models in limbo, highlighting how expired extenders tied to government funding decisions can disrupt operations and innovation in health care delivery.
OIG Finds Widespread "Ghost Networks" in Medicare Advantage and Medicaid Mental Health Provider Directories
A new report from the Office of Inspector General (OIG) found that 55 percent of mental health professionals listed as in-network for Medicare Advantage plans were not actually treating plan members. For Medicaid managed care plans, the figure was 28 percent. The review, which examined 40 Medicare Advantage and 20 privately managed Medicaid plans, identified widespread “ghost networks,” where providers were listed at multiple locations despite being retired, unlicensed, or not contracted with the plan. Read more here.
Why It Matters
The OIG report arrives as the Trump administration finalizes requirements for MA plans to publish provider directories on Medicare Plan Finder for 2027 open enrollment, providing empirical justification for stricter enforcement of the new 30-day update windows and annual attestations. CMS's parallel development of a national provider directory and partnership with third-party data vendors signals a shift toward independent verification rather than plan self-reporting. MA plans now face pressure to invest in directory accuracy technology and expand mental health networks while managing legal liability risks.
Look for the Helpers: ChristianaCare Invests in Delaware’s Community Health Workforce
In Delaware, ChristianaCare is strengthening local health infrastructure through a $26,500 investment to launch the state’s first certification program for community health workers. The program equips participants with the training and tools to connect older adults living with chronic conditions like diabetes and hypertension to care coordination, social supports, and community resources. By building a sustainable workforce rooted in trust and local engagement, the initiative helps close gaps in care while fostering healthier, more connected communities. Read more here.
What We're Writing
Bridging Medicaid and Public Health: Turning Shared Goals into Shared Systems
Our latest blog explores how states can move beyond coordination between Medicaid and public health toward building integrated, value-based systems. It highlights practical strategies such as aligning governance structures, co-funding roles like community health workers and doulas, and developing shared performance metrics to advance goals in maternal health, chronic disease, and behavioral health. Read the full blog post here.
What We Are Reading
Health Benefits In 2025: Family Premiums Rise 6 Percent, Large Employers Increase Coverage Of GLP-1s For Weight Loss
A Health Affairs analysis shows that the average annual premium for employer-sponsored family health coverage surged to $26,993 in 2025, an increase of $1,408 (6 percent) compared to the previous year. Read here.
Medicaid Cuts Threaten Pregnancy And Postpartum Coverage, Access To Care, And Health
An article from Health Affairs Forefront argues that significant reductions in Medicaid funding and eligibility will jeopardize access to prenatal and postpartum services, particularly in rural areas and among historically underserved populations, potentially worsening maternal and infant health outcomes. Read here.
What We're Attending
Closing the Distance in Rural Primary Care: Evidence, Stories and Solutions
Join the Primary Care Collaborative (PCC) on November 12, 2025 at 1:30 pm ET for the release of its 2025 Evidence Report. The session will present case studies and data-driven insights into how rural primary care is adapting to new barriers in access and coverage, followed by a policy-focused panel offering actionable solutions. Register here.
Pop Health Podcast
Rural Health Transformation: How States Can Align Stakeholders for Lasting Change
The Rural Health Transformation Program represents a $50 billion investment in the future of rural health care. In this episode, we sit down with Caitlin Westerson, Senior Director for State Policy and Advocacy at United States of Care, to explore what this program means for states, providers, and communities. Together, we unpack the opportunities and challenges in applying for funding, the role of value-based care in building sustainable models, and how states can align stakeholders to create lasting change in rural health systems.