Insights

On September 10, 2025, the House Energy and Commerce Health Subcommittee held a markup of 7 public health reauthorization bills. Many of these bills were discussed at the Subcommittee in a legislative hearing on July 9, 2025.  It is expected that most if not all these rather non-controversial bills will be voted on at the full committee in the next week or so.

Opening Statements

• Health Subcommittee Chairman Morgan Griffith (R-VA) emphasized that the markup represents a pivotal step toward securing reauthorization of essential public health programs before they expire at the end of the fiscal year. Expert testimony from the July hearing helped inform the subcommittee’s understanding of their impact on communities and health systems. Among the measures under review, Chairman Griffith highlighted the importance of reauthorizing Title VII and Title VIII programs, which play critical roles in bolstering the nation’s health care workforce.
• In his opening remarks, Ranking Member Frank Pallone (D-NJ) highlighted seven bills to strengthen key public health programs. He emphasized reauthorizing HRSA’s Title VII and VIII workforce programs to address provider shortages and boost diversity. He also underscored the Healthy Start Program to improve maternal and infant health, and newborn screening programs that save thousands of lives annually. Ranking Member Pallone also called for restoring expert guidance on newborn screening and ensuring parental leave parity for U.S. Public Health Service officers to support recruitment and retention.

Legislation Included in the Markup

H.R. 4262. This legislation would reauthorize through FY 2030 health care workforce education and training programs in Title VII of the Public Health Service Act (PHSA). Passed by voice vote with amendment.

H.R. 3593.  This legislation would reauthorize through FY 2030 nursing workforce development programs from Title VIII of the PHSA. Passed by voice vote.

H.R. 2493, Improving Care in Rural America Reauthorization Act of 2025.  This legislation would reauthorize through FY 2030 grant programs for rural health care services outreach, rural health network development, and small health care provider improvement. Passed by voice vote.

H.R. 3419.  This legislation would reauthorize the telehealth network and telehealth resource centers grant programs through FY 2030. Passed by voice vote.

H.R. 3302, the Healthy Start Reauthorization Act of 2025.  This legislation would reauthorize the Healthy Start program through FY 2030.  Passed by voice vote.

H.R. 2846, to allow commissioned Public Health Service offices to access leave as commissioned officers of the Army do. Passed by voice vote.

H.R. 4709, the Newborn Screening Saves Lives Reauthorization Act of 2025.  This legislation would reauthorize through FY 2030 certain programs and activities related to newborn screening of heritable disorders. Passed by voice vote.

On September 16, 2025, the House Ways and Means Oversight Subcommittee held a hearing on examining the role of tax-exempt hospitals, the sustainability of rural health care, and the future of Affordable Care Act premium tax credits (APTCs). Members debated whether current policies enable hospitals to fulfill their charitable missions, the impact of Medicaid expansion and proposed Medicaid cuts, and the need to extend premium tax credits set to expire at the end of this year.

WITNESS TESTIMONY

• Dr. Ge Bai, PhD, Professor of Health, Policy, and Management, Johns Hopkins Bloomberg School of Public Health – Testimony

• William Hild, Executive Director, Consumers’ Research – Testimony

• Dr. Christopher Whaley, PhD, Associate Director, The Center of Advancing Health Policy through Research, Brown University – Testimony

• Dr. Stanley Goldfarb, Chairman of the Board, Do No Harm – Testimony

• Dr. Jill R. Horwitz, Trobman Family Innovation Professor, Northwestern University Pritzker School of Law and Professor of Emergency Medicine, Northwestern Feinberg School of Medicine – Testimony

MEMBER DISCUSSION

Rural Hospital Viability

Rep. Gregory Murphy (R-NC-03) raised concerns about how rural hospitals can continue to survive in today’s strained health care environment. Dr. Whaley argued that strengthening competition and markets is essential to protecting rural hospitals, while Dr. Horwitz emphasized that without nonprofit hospitals, many rural communities would lose access to hospital services altogether. Members repeatedly acknowledged that rural hospitals face unique challenges, including shrinking patient populations, limited provider networks, and dependence on Medicaid and Medicare, which leave them financially vulnerable.

Medicaid Expansion and Savings

Rep. Terri Sewell (D-AL-07) asked how Medicaid expansion has affected the provision of community benefits, noting that expansion has enabled hospitals to treat more low-income individuals. Rep. Judy Chu (D-CA-28) built on this by asking how potential cuts to Medicaid would affect nonprofit hospitals, given their reliance on Medicaid reimbursements. Dr. Horwitz warned that cuts under the reconciliation bill would reduce hospitals’ ability to provide uncompensated care and limit their capacity to respond to community needs.

Rep. Suzan DelBene (D-WA-01) pressed witnesses on what Congress could do to help hospitals at a time when health care feels “under attack.” Dr. Horwitz responded that clearer IRS guidance could help nonprofit hospitals remain compliant with their obligations while ensuring they continue to serve vulnerable patients.

Affordable Care Act Premium Tax Credits (APTCs)

Rep. Thomas Suozzi (D-NY-03) highlighted that APTCs are set to expire at the end of December, warning that without congressional action, insurance rates could rise dramatically. He stressed that there is bipartisan recognition of the need to extend the credits. Mr. Hild agreed, emphasizing that affordability is the key concern for families, while Dr. Goldfarb echoed the affordability issue though acknowledged limited expertise in this area. Dr. Bai opposed extension, contending that subsidies do not address underlying problems and that insurance does not equate to true coverage. Dr. Whaley and Dr. Horwitz countered that rising hospital costs are fueling premium increases and warned that without extending APTCs, more Americans would lose coverage as insurance prices continue to climb.

On September 18, 2025, the Medicaid and CHIP Advisory Commission (MACPAC) convened for the first day of its September meeting. Commissioners examined work and community engagement (WCE) requirements in Medicaid, heard from a panel of experts on the challenges and implications of implementing requirements, and later turned to Medicaid payment policies aimed at strengthening the home- and community-based services (HCBS) workforce.

WORK AND COMMUNITY ENGAGEMENT REQUIREMENTS IN MEDICAID

MACPAC staff reviewed the history and status of Medicaid WCE requirements. Initially tested through Section 1115 demonstrations, MACPAC’s staff findings found these efforts led to significant coverage losses due to administrative hurdles and compliance barriers, with Arkansas being the only state to fully disenroll beneficiaries before courts halted most programs. Georgia’s “Pathways to Coverage” remains the only active demonstration, though enrollment has been lower than expected, particularly for older adults.

MACPAC staff detailed how the 2025 Budget Reconciliation Act, mandates certain non-pregnant, non-dually eligible adults aged 19–64 to complete 80 hours per month of work, education, or community service—or demonstrate income at the federal minimum wage equivalent—to maintain Medicaid coverage. The law establishes numerous exemptions (e.g., caregivers, medically frail individuals, American Indians/Alaska Natives, veterans with disabilities) and hardship provisions, requires monthly compliance checks and clear notices, and sets a national implementation deadline of January 2027 (with possible extensions to 2028). Federal funds totaling $400 million have been allocated to support both state implementation and federal oversight. MACPAC staff noted that policymakers and stakeholders remain concerned that, despite exemptions, the new requirements could still result in administrative complexity and coverage losses similar to past demonstrations.

During the discussion, commissioners asked staff to clarify how community engagement requirements would apply across different eligibility groups. One commissioner questioned whether non-expansion states would be affected if they expanded coverage through Medicaid Group A, and staff explained that the requirement is limited to individuals applying under that group. Questions were also raised about past state experiences, such as how many beneficiaries in Arkansas lost coverage due to work requirements, though staff noted that data was not available. Commissioners expressed interest in how the Centers for Medicare and Medicaid Services (CMS) is encouraging states to address difficult implementation questions, how states are approaching definitions and reporting, and what lessons can be learned from their unwinding experiences. MACPAC staff agreed that they will expand their research to include these items.

The conversation also touched on program design and oversight. Commissioners asked about how states handle job-based training, with staff emphasizing that approaches differ across demonstrations. They also explored the mechanisms available for implementation, such as state plan amendments, and whether the statute provides clear guidance on how these plans should be carried out. Commissioners inquired about state investments relative to enrollment levels, available data sources to evaluate the impact of work requirements, and the specifics of postpartum eligibility, which staff noted typically reflects state policy and can extend up to 12 months. Finally, there was interest in whether 1115 waivers remain part of the pathway and concerns that the 90-day window for compliance may be overly aggressive.

PANEL ON WORK AND COMMUNITY ENGAGEMENT REQUIREMENTS IN MEDICAID

MACPAC next convened a panel on Work and Community Engagement (WCE) requirements. Jennifer Strohecker, Integrated Healthcare Division and Medicaid Director of Utah Department of Health and Human Services, opened by urging a beneficiary-first approach: start with the individual who qualifies for Medicaid and map the specific barriers that keep them from accessing or keeping coverage—especially those living with chronic conditions. She described building an internal project team aligned on budget, activities, and evaluation, beginning early outreach so stakeholders can engage alongside federal partners, and designing processes that minimize gaps and churn. Melisa Byrd, Senior Deputy Director and Medicaid Director, District of Columbia Department of Health Care Finance, emphasized that currently not all states are subject to WCE, therefore, some need clear guidance on what counts as compliant. She also noted that D.C. is actively planning for work-related requirements outside the reconciliation bill framework, while broader policy discussions continue.

Operational lessons featured prominently. Using Georgia as a case example, panelists said applicants interact through the Gateway system; the biggest friction was not the work requirement itself but rural connectivity and document-upload challenges—phones and bandwidth, which often blocked compliance. Self-employment was recognized as an allowable pathway, and the program served as a test bed for clarifying which payment/verification systems would be used. Turning to implementation mechanics, Jessica Kahn, Partner of McKinsey & Company, explained that exemptions drive complex “business rules” and logic: states must decide the hierarchy of checks—what gets verified first, with what data, and how conflicts are resolved—because each exemption can touch multiple modules. Deanna Williams, Enrollment Assister at Georgians for a Healthy Future, argued for robust in-person and virtual support centers so beneficiaries can complete applications and troubleshooting without losing coverage.

Commissioners had a range of questions that centered around governance, data, and capacity. One commissioner flagged data-privacy concerns, particularly if states contemplate pulling payroll tax. Another asked whether states are exploring performance or integrity indicators to monitor WCE implementation quality and detect problems early. A commissioner highlighted that Medicaid directors bring significant operational capacity but asked what specific capabilities are most needed now; Ms. Strohecker answered by urging states to build internal muscle rather than default to outside consultants and to be candid about what they must say no to given limited resources. Other questions included requesting clear escalation pathways to prevent beneficiary issues from languishing at the help desk tier and advocating for rigorous cost–benefit analysis to ensure the administrative complexity of WCE yields measurable coverage stability, employment connection, or other outcomes that justify the investment.

MEDICAID PAYMENT POLICIES TO SUPPORT THE HOME- AND COMMUNITY-BASED SERVICES WORKFORCE (HCBS)

MACPAC staff next turned their attention to Medicaid payment policies to support the HCBS workforce. They highlighted the central role of wage data in setting rates that sustain an adequate direct care workforce. States typically rely on Bureau of Labor Statistics (BLS) data, but these measures are not specific to Medicaid and exclude many HCBS worker types, forcing states to blend or supplement data. The new CMS “Ensuring Access” rule will require states to publish average HCBS payment rates (starting 2026) and report compensation percentages (starting 2028), but it does not require reporting of wage levels nor make the data public, leaving major gaps for states trying to benchmark and plan.

MACPAC staff presented a draft recommendation calling to require CMS to collect and publish biannual, service-specific hourly wage data (personal care, home health aide, homemaker, habilitation), disaggregated by worker type and geography. Publishing descriptive statistics like mean, median, and range would give states more robust, comparable data to set rates, while building on existing access rule reporting to minimize new burdens. recommendation notes this would have no federal budget impact, require only marginal additional effort from states and providers, and could strengthen HCBS workforce recruitment and access to services over time. A vote on the recommendation is scheduled for October 2025, draft chapter for the March 2026 report to Congress to follow.

During the discussion, commissioners pressed staff on how Medicaid wage reporting for the HCBS workforce should be structured. Some asked whether family caregivers paid through self-direction programs would be included, and staff explained that it would depend on what each program requires states to report. Others raised concerns about the clarity of the recommendation’s language, suggesting changes such as removing the “biannual” requirement and replacing “mean, median, and range” with more flexible terminology like “average.” Questions also emerged about whether the Secretary of the Department of Health and Human Services (HHS) could simply refine or expand the existing CMS access rule reporting requirements rather than duplicating them, with some commissioners expressing unease about states potentially needing to shoulder higher rates as a result.

Several commissioners emphasized that building on the access rule was the intent, ensuring consistency rather than creating new burdens. There was debate over the value of collecting and publishing only averages versus providing a fuller distribution of wage data, with supporters arguing that median and range figures give a more accurate picture of workforce realities. Commissioners also asked about the frequency of data collection, weighing the benefit of annual versus biannual reporting if states are already gathering similar information. Overall, the conversation reflected broad support for improving wage transparency but lingering disagreements about the best language, frequency, and level of detail to include in MACPAC’s recommendation.

On September 19, 2025, the Medicaid and CHIP Advisory Commission (MACPAC) met for the second day of its September session, focusing on key takeaways from the implementation of the enhanced federal medical assistance percentage (FMAP) for home- and community-based services (HCBS) under the American Rescue Plan Act (ARPA), as well as issues related to the Medicare Medicaid transition.

IMPLEMENTATION OF INCREASED FMAP FOR HCBS UNDER THE ARPA: KEY TAKEAWAYS

MACPAC staff reviewed how states used the temporary 10 percent FMAP increase authorized under the ARPA. Research found the enhanced match, available from April 2021 through March 2022, was intended to supplement—not supplant—state spending and required states to invest in activities that enhanced, expanded, or strengthened HCBS. Together, federal and state dollars generated an estimated $37 billion for reinvestment through the FMAP increase. CMS oversaw the initiative through guidance letters, required quarterly spending plans, and semi-annual progress reports. While the funds were initially set to expire in March 2024, spending deadlines were extended to March 2025, with about half of states receiving further extensions into 2026.

MACPAC staff reported that most states directed their funds toward HCBS workforce initiatives, including recruitment, retention, and training, with additional investments in quality improvement, reducing waiting lists, and cross-system partnerships. However, states faced significant challenges with timing, as they had only a short window to develop and submit spending plans, making robust stakeholder engagement and planning difficult. Administrative hurdles, such as hiring staff and making waiver or plan amendments, further constrained implementation. Evaluation was also limited, as the law did not require comprehensive assessments of funded activities, and states often lacked capacity, data, or time to measure outcomes. Another large concern was sustainability: although two-thirds of states included some plans to maintain activities beyond the funding period, only about one-third of workforce-related initiatives appear likely to be sustained. In many cases, funds were used for temporary relief or stopgap measures rather than long-term system improvements. The next steps include publishing an issue brief that summarizes the monitoring activities and the lessons learned to date.

MEDICARE-MEDICAID PLAN TRANSITION

MACPAC staff next outlined progress and challenges in shifting from the Financial Alignment Initiative (FAI) demonstration’s Medicare-Medicaid Plans (MMPs) to integrated Dual Eligible Special Needs Plans (D-SNPs) in states where FAI ends in 2025 (including IL, MA, MI, NY, OH, RI, SC, TX). Most states have completed procurements and are set to transition to D-SNPs by January 1, 2026. States reported that while procurement was complex—often delayed by bid protests or misaligned state and Medicare Advantage timelines—they are largely confident in their ability to meet the transition. In terms of enrollment and IT changes, the transition entails moving from broker-based enrollment to a process in which the D-SNP handles Medicare enrollment while the state handles Medicaid. This shift introduces potential for timing mismatches, which states are addressing via system updates and coordination to avoid enrollment lags. Stakeholder engagement is also a focus, and states are actively communicating with beneficiaries, plans, and advocates. States are also developing guidance and limiting unnecessary notices to reduce confusion. MACPAC’s next step is to continue monitoring how states manage these shifts to identifier systems, deployment of new policies, beneficiary communication, and operational readiness.

Commissioner discussion highlighted significant concerns about the transition from MMPs to integrated D-SNPs. Commissioners noted the daunting nature of the process for dual eligibles, raising questions about whether the integrity of D-SNPs will hold up and whether plans may push back against integration efforts. They emphasized the complexity of aligning CMS, Medicare, and Medicaid requirements, cautioning that this transition poses larger systemic challenges. Continuity of care also emerged as a key issue, with worries about how many beneficiaries may lose access to their providers or benefits, and how disruptive the shift might feel for enrollees accustomed to the current model. While some elements of the transition are still in flux, commissioners underscored the importance of maintaining a strong focus on consumer experience, tracking outcomes, and ensuring that both Medicaid and CHIP programs continue to play their critical roles in meeting the needs of vulnerable populations.