Federal Health Policy Update
Recent federal health policy changes, including provisions of the 2025 reconciliation bill H.R. 1, sometimes referred to as the One Big Beautiful Bill Act, will impact services related to healthcare, housing, food access and more. HPIO’s Federal Health Policy Update provides an overview of relevant changes to national health policy (e.g., bills passed, implementation deadlines, new guidance) and how Ohio could be affected. It also highlights state policy decisions that will need to be made by Governor-elect Amy Acton, her administration and the incoming 137th Ohio General Assembly.
If you have questions about the newsletter or have suggested tools or resources you would like to see included in future editions, please contact Nick Wiselogel, HPIO’s Vice President of Communications and Design.
► HPIO graphic: Medicaid enrollment trend
Ohio Medicaid enrollment has been declining for the past three years, since peaking in state fiscal year 2023, according to Ohio Department of Medicaid caseload reports, as illustrated above.
Most of the decline is from people enrolled through the Medicaid expansion category, which covers working-age adults with low incomes, and the Covered Families and Children (CFC) group, which covers children in families with low incomes, as well as pregnant women, parents and related caregivers.
Total enrollment has now reached its lowest point in Ohio since 2020, near the start of the COVID-19 public health emergency (PHE). During COVID-19, enrollment reached a high of 3.5 million people in 2023 due to provisions of the PHE, allowing people to remain continuously enrolled. When the PHE ended and normal eligibility processes resumed in April 2023, often referred to as “unwinding,” enrollment expectedly declined. However, despite the end of unwinding in March 2024, enrollment has dropped even further to 2.9 million Ohioans as of August 2026.
H.R. 1 is expected to cause significant changes to Ohio’s Medicaid program, with many of the Medicaid provisions in the law set to be implemented in 2027. Given these upcoming changes to Medicaid, measurement of H.R. 1-related impacts on Ohio’s Medicaid program will require careful attention to baseline enrollment levels at the time new provisions go into effect.
► Federal policy tracker
Upcoming federal policy implementation considerations:
Medicaid work reporting requirements begin (Jan. 1, 2027)
H.R. 1 mandates that all states implement work requirements for Medicaid enrollees who are covered through the expansion (also called Group VIII) category. On Jan. 1, 2027, Ohio will begin mandating that Medicaid expansion enrollees meet these work and community engagement reporting requirements or have an eligible exemption, such as medical frailty.
Any new applications for coverage after this date will be evaluated for the requirement using a one-month lookback. For existing enrollees, compliance will be verified at the next renewal date. Disenrollments are expected to begin as early as May 2027 for individuals who are determined to not meet the requirements and who do not provide additional documentation.
Related HPIO resources:
- Policy update: Implementation of Medicaid work requirements in Ohio
- Medicaid Work Requirements in Ohio
More frequent Medicaid eligibility determinations (Jan. 1, 2027)
In addition to new work reporting requirements, H.R. 1 also increases the frequency of eligibility redeterminations for Medicaid expansion enrollees. Medicaid expansion enrollees will undergo renewals every six months rather than every 12 months. The Ohio Department of Medicaid anticipates that this policy change will increase caseloads for county Job and Family Services offices, which are responsible for verifying program eligibility in Ohio.
Related HPIO resources:
Affordable Care Act (ACA) marketplace open enrollment (Nov. 15, 2026 – Jan. 15, 2027)
Open enrollment for 2027 coverage through the federal health insurance marketplace begins on Nov. 15., Marketplace enrollment in Ohio declined by more than 32% in 2026 following the expiration of enhanced subsidies at the end of 2025. Enrollment is expected to decline even further as premiums continue to increase. Due to the rising cost of healthcare and ongoing instability following the expiration of enhanced subsidies, Ohio marketplace premiums are increasing by an average of 15% in 2027, and two insurers (CareSource and Molina) decided to no longer offer marketplace plans in Ohio. These changes, alongside ongoing H.R. 1 implementation, will likely contribute to a higher uninsured rate in the state.
Related HPIO resource:
- Updated Ohio enrollment in the federal ACA marketplace
- Policy explainer: Changes to the federal health insurance marketplace
Rural Health Transformation program funding (ongoing)
In the first year of the federal Rural Health Transformation (RHT) Program, Ohio received approximately $202 million, one of the lowest amounts in the nation based on rural population size.
Year one funding ran through Sept. 30, 2026, and CMS expected states to submit their first formal reports beginning Oct. 1, 2026. Year 2 funding was expected to be released on Oct. 31, but those awards have been delayed.
More information about Ohio’s plans for the funding is available at the Ohio Department of Health’s RHT site.
Related HPIO resources:
- Rural Health Transformation Program funding in Ohio
- Data snapshot: Health in rural and Appalachian Ohio
► Resources and tools
Medicaid
- Medicaid Work Reporting Requirements After the Medical Frailty Ruling: State Decisions and Implementation Priorities — State Health & Value Strategies (Princeton University)
- What H.R. 1’s Changes to Medicaid Payment Error Rules Mean for States — The Commonwealth Fund
- A Framework for Monitoring the Impact of H.R. 1 Work Reporting Requirements and Six-Month Renewals — State Health & Value Strategies (Princeton University)
- State Fiscal Conditions: Context on Medicaid Budgets for FY 2027 — KFF
ACA marketplaces
- 9 Things to Watch for the 2027 ACA Open Enrollment Period — KFF
- More ACA Premium Spikes to Come in 2027 Amid Federal Policy Changes — Commonwealth Fund
- No Good Options: In the Wake of Marketplace Affordability Woes, Consumers Face Onslaught of Misleading Marketing of Limited Benefits Products — Georgetown University Center on Health Insurance Reforms
- Implementation of Immigrant Eligibility Restrictions for ACA Marketplace Subsidies Under the 2025 Reconciliation Law: Issues to Consider — KFF
Rural Health Transformation Program
- RHTP RFP Status by State — National Rural Health Association
- A Closer Look at the $50 Billion Rural Health Transformation Program — KFF
- Launching Rural Health Transformation Plans: Lessons from Other Large-Scale State Initiatives — Center for Health Care Strategies
Other
- The State of Health Insurance Coverage in 2026 — The Commonwealth Fund
- Private Health Insurance Basics — HPIO
Past editions of Federal Health Policy Update
