Congressional End-of-Year Outlook: Health Care and Beyond

In the aftermath of the One Big Beautiful Bill Act (OBBB), Congress must now refocus its attention on several outstanding priorities that need to be addressed before the end of the year. In March, Congress passed a Continuing Resolution (CR) that extended government funding through the end of fiscal year (FY) 2025 (Sept. 30, 2025). The CR included a number of health care extenders and other provisions that must now be dealt with ahead of their expiration. Should the deadline pass, these programs would face steep funding cuts or fully expire.

The expiration of the enhanced Advance Premium Tax Credits (eAPTCs) at the end of the calendar year (Dec. 31, 2025) is also at the top of the health care sector’s mind. Furthermore, the National Defense Authorization Act (NDAA) and the Farm Bill (Crop Year Programs) must also all be addressed by the end of the year.

Although Congress continues to move slowly through the appropriations process, it remains to be seen whether they have the appetite to pass all 12 appropriations bills through both chambers, all while juggling recissions and potentially additional reconciliation packages. To date, the House has passed two appropriations bills on the floor while the Senate has only passed four through committee, and none on the floor. Congress must pass an appropriations package or a CR by Sept. 30 to avoid a government shutdown. Further complicating the timeline is the August recess. The House left town on Wednesday, June 23, and the Senate is scheduled to leave on Friday, Aug. 1. Both chambers return on Tuesday, Sept. 2.

These upcoming cliffs follow the collapse of a substantial bipartisan health care package last December, which would have included longer Medicare and Medicaid public health extenders, full reauthorization of the SUPPORT Act and Pandemic and All-Hazards Preparedness and Response Act (PAHPA), pharmacy benefit manager (PBM) reforms and bipartisan legislation, including those addressing sickle cell disease, maternal health, organ procurement and pediatric studies of drugs. The package was ultimately dropped from the year-end stopgap spending deal due to political disagreements, putting unresolved priorities back on the table for a future legislative vehicle.

Nonetheless, these cliffs provide an opportunity for other health care priorities to move forward, including policies that were dropped from the One Big Beautiful Bill (OBBB) during the negotiation process, like PBM reform, or policies that fell out due to “Byrd Rule” challenges or a lack of consensus, like the prohibition of federal funding for gender transition procedures.

A breakdown of the expiring provisions can be found below.

Expiring Sept. 30, 2025

Health Care Extenders

• Community Health Center (CHC) Funding: CHCs provide primary care to millions of low-income, uninsured and underserved patients. The current CR provides approximately $2.1 billion in appropriated funding through the end of FY 2025. In comparison, the failed bipartisan health care package would have increased CHC funding to $4.6 billion. Without reauthorization, CHCs may experience considerable financial instability, limiting their capacity to deliver treatment, expand services or maintain workforce levels.

• National Health Service Corps (NHSC): The NHSC supports scholarships and loan repayments for health care workers serving in high-need areas. The current CR maintains funding at approximately $173 million and only reauthorized the program for the current fiscal year. The failed end-of-year package proposed a two-year extension with $262 million for FY 2025 and $350 million for FY 2026. Without reauthorization, health care workforce shortages in rural and underserved communities could worsen.

• Teaching Health Center Graduate Medical Education (GME) Programs: Teaching Health Center GME programs train primary care residents in community-based settings, helping address physician shortages. The current CR extends funding to approximately $88 million and only reauthorizes it through the end of the current fiscal year. However, the failed year-end package proposed reauthorization through FY 2029. Training programs that serve vulnerable populations face significant funding cliffs if they are not reauthorized.

• Special Diabetes Program (SDP): The SDP funds Type 1 diabetes research and prevention efforts in at-risk populations. The current CR maintains around $80 million in appropriated funding and reauthorizes the program through the end of the fiscal year. The year-end health care package, by comparison, included a two-year extension with $150 million for FY 2025 and $200 million for FY 2026. Without action, the program expires on Sept. 30, jeopardizing key research and treatment efforts.

• National Health Security Extensions: National health security programs support the U.S. response to health threats, including pandemics and bioterrorism. These include funding for the Assistant Secretary for Preparedness and Response (ASPR) authority as well as partnerships under the Biomedical Advanced Research and Development Authority (BARDA). The current CR only authorizes the programs through the end of the fiscal year. It included some provisions from PAHPA, including the authorization of BARDA, authority of the Department of Health and Human Services (HHS) secretary to declare a public health emergency, and antitrust exemptions for the development of emergency medical countermeasures. The CR also ensures authority for state and local health departments to exercise flexibilities during a public health emergency. The EOY package included temporary extensions to select national health security provisions, such as reauthorizing pieces of PAHPA for two years. Failure to reauthorize a more comprehensive package leaves gaps in emergency preparedness infrastructure.

• Low-Volume Adjustment (LVA) Program: The increased inpatient hospital payment adjustment for certain low-volume hospitals provides higher Medicare payments to rural hospitals with low patient volumes to ensure financial viability. The current CR only extends the LVA program through the end of the fiscal year; however, the failed end-of-year package included a one-year extension through FY 2026. Without reauthorization, these hospitals face reduced reimbursement and potential closures.

• Medicare-Dependent Hospital (MDH) Program: The MDH program supports small, rural hospitals that serve a high proportion of Medicare patients. The current CR only extended the program through the end of this fiscal year, in line with the failed year-end package, which also only extended it for one year. These hospitals risk significant funding losses without congressional action.

• Add-On Payments for Ambulance Services: Medicare add-on payments help cover the high costs of ambulance services in rural and super-rural areas. The current CR only extends the program through the end of this fiscal year. However, the failed end-of-year package would have provided a two-year extension. Without reauthorization, ambulance providers may scale back services in underserved areas.

• Funding for Quality Measure Endorsement, Input and Selection: This funding supports the development and endorsement of clinical quality measures used across Medicare and Medicaid. It helps maintain accountability in federal health programs and is at risk if not addressed. The current CR funds the program at approximately $14 million, which would expire at the end of the 2025 fiscal year if not extended.

• Extension of Funding Outreach and Assistance for Low-Income Programs: This section provides funding for state health insurance assistance programs ($30 million), including area agencies on aging ($30 million), aging and disability resource centers ($10 million) and coordination efforts to inform older Americans about benefits available under federal and state programs ($30 million). The CR temporarily extended funding to the end of the fiscal year.

• Extension of Work Geographic Index Floor: This provision helps prevent Medicare physician payment cuts in low-cost geographic areas by establishing a floor for the work component of the physician fee schedule (PFS). The current CR extends the 1.0 work Geographic Practice Cost Index (GPCI) floor used in the calculation of payments under the Medicare PFS through the end of the current fiscal year. It directly supports rural provider payment stability, which would be at risk if the GPCI is not extended.

• Medicare Telehealth Flexibilities: As a carryover from the COVID-19 pandemic, Medicare has continued to allow certain telehealth flexibilities. This includes removing certain geographic requirements and expanding originating sites for telehealth services, expanding practitioners eligible to provide telehealth services, extending telehealth services for Federally Qualified Health Centers (FQHCs) and rural health clinics, delaying the in-person requirements under Medicare for mental health services provided through telehealth, allowing for audio-only telehealth services and extending the use of telehealth to conduct face-to-face encounters prior to recertification of eligibility for hospice care. The failed December health care package would have extended telehealth flexibilities for two additional years. The current CR only extends these flexibilities through the end of this fiscal year.

• Acute Hospital Care at Home Waiver Authorities: These waivers allow hospitals to deliver inpatient-level care in patients’ homes, increasing capacity and reducing costs. The current CR maintains reauthorization for the Acute Hospital Care at Home initiative through the end of the 2025 fiscal year. However, the failed end-of-year package proposed extending the waiver through FY 2026. Without action, flexibilities granted during the pandemic will lapse, impacting hospital operations and patient choice.

• Medicare Improvement Fund: The Medicare Improvement Fund is currently funded at $1.8 billion. The purpose of the fund is to generally improve the original Medicare program, primarily Parts A and B, in ways that may include adjusting the amounts that Medicare pays to health care providers and suppliers. The EOY health care package would have funded the initiative at a similar level.

• Medicaid Disproportionate Share Hospital (DSH) Cut Delay: The Affordable Care Act (ACA) scheduled cuts to Medicaid DSH payments, but Congress has routinely delayed them due to hospitals’ reliance on the funding. The current CR extends the delay through the end of FY 2025. However, pending further action by Congress, the DSH cuts would go into effect starting in FY 2026 through FY 2028.

Other Expiring Provisions

• Farm Bill (Fiscal Year Programs): There are two principal expiration dates for the Farm Bill as currently extended. The first is the expiration of the Farm Bill on Sept. 30, 2024, for programs with fiscal year authorizations. Programs that rely on mandatory funding authorizations in the Farm Bill are the most impacted by expiration. The expiring programs broadly cover commodities, conservation and nutrition, representing nearly 92% of mandatory funding available. Other titles that would be affected include programs in trade, research, energy and horticulture. OBBB included several changes to the commodity, crop insurance, conservation, trade, livestock disaster assistance and nutrition programs, but it did not reauthorize the full Farm Bill. Many remaining provisions, particularly those under the nutrition and conservation titles, must be addressed before the current Farm Bill extension expires at the end of FY 2025.

• National Flood Insurance Program (NFIP): NFIP is managed by the Federal Emergency Management Agency (FEMA) and aims to reduce the impact of floods by providing affordable flood insurance to renters, businesses and property owners. It is delivered to the public by a network of more than 47 insurance companies and the NFIP Direct, which helps beneficiaries recover faster when floodwaters recede. The NFIP also works with communities required to adopt and enforce floodplain management regulations that help mitigate flooding effects. NFIP was extended through the end of the fiscal year in the CR.

• Temporary Assistance for Needy Families (TANF): TANF is designed to help low-income families and children achieve economic security and stability. Specifically, states receive block grants to design and operate programs that accomplish the purposes of the TANF program. Although jurisdictions must meet certain work participation and cost-sharing requirements, they have considerable flexibility with TANF funds to implement programs that best serve the needs of their communities. The TANF program was extended through the end of the fiscal year in the CR.

• Defense Production Act (DPA): The DPA provides the president with an array of authorities to shape national defense preparedness programs and take appropriate steps to maintain and enhance the domestic industrial base. Over the last several decades, many administrations have used the DPA as a tool to manage the nation’s defense and nondefense productive capacity, such as invoking authorities to increase the domestic supply of goods and materials. Broadly, it covers allocations, expansion of productive capacity and supply, and other authorities to establish voluntary agreements with industry or obtain information about the industrial base. The DPA is set to expire on Sept. 30.

• Cybersecurity Information Sharing Act (CISA): CISA is intended to improve cybersecurity by encouraging the sharing of cyberthreat indicators and other defensive measures between the private sector and government. It also provides liability and legal protection for organizations that share cybersecurity threat information. Historically, there have been many competing proposals across both chambers hoping to make changes to the original bill. The reauthorization is set to sunset on Sept. 30.

Expiring Dec. 31, 2025

• Enhanced Advance Premium Tax Credits (eAPTCs): As part of the Inflation Reduction Act (IRA), Congress passed a three-year extension of enhanced subsidies for individuals purchasing their own health coverage on the ACA Marketplace. These temporary subsidies, now expiring at the end of 2025, were first passed as part of the American Rescue Plan Act (ARPA) in March 2021, and were originally slated to last two years. The eAPTCs increase the amount of financial assistance available to those who are already eligible (households with an income of at least 100% of the federal poverty level (FPL) or above 138% in states that have expanded Medicaid), and also newly expanded subsidies to middle-class Americans (households with an income above 400% FPL), thereby temporarily preventing steep increases in marketplace premium payments for subsidized enrollees—so long as the extension is in place. Without a further extension in 2025, it is anticipated virtually all of the 19.7 million subsidized enrollees will see some increase in their out-of-pocket premium payments. Furthermore, the Congressional Budget Office (CBO) has estimated marketplace enrollment would drop from an estimated 22.8 million in 2025 to 18.9 million the following year, reaching as low as 15.4 million in 2030. Democrats have continued to urge Congress to move as quickly as possible to ensure the eAPTCs do not expire. A poll from KFF showed that a large majority (77%) of the public favors Congress extending the credits. Although Republicans broadly remained opposed, as a result of the OBBB’s Medicaid cuts, some members, including Sens. Lisa Murkowski (R-AK) and Dan Sullivan (R-AK), have expressed support for bipartisan talks to extend the credits.

• National Defense Authorization Act (NDAA): The House Armed Services Committee (HASC) overwhelmingly passed its version of the FY 2026 NDAA by a vote of 55–2 on July 16. Key to this year’s bill are efforts to revamp the defense industrial base and improve procurement efficiency. Specific components include the SPEED Act, which proposes a new directorate to streamline defense acquisition by reducing red tape and accelerating delivery timelines for military equipment. This builds on language in the Senate Armed Services Committee (SASC)-passed version that was shaped in part by the FORGED Act, indicating significant bipartisan support for such reforms. SASC also recently issued its committee report, with the HASC committee report expected next. Leadership is aiming to have the bill on the House floor in early September, following the August recess. The Senate will subsequently release a manager’s package. Both chambers will move to conference in late fall or early winter before final passage, which must occur before the end of the calendar year, likely before the December recess.

• Farm Bill (Crop Year Programs): The second expiration date for the Farm Bill impacts the farm commodity support programs authorized on the basis of crop years, referring to the calendar year during which a crop is harvested. This includes programs that support farm income by making payments and reducing financial risks from uncertain weather or market conditions, such as the Marketing Assistance Loan (MAL) program, Loan Deficiency Payments (LDP), Price Loss Coverage (PLC) program, Agriculture Risk Coverage (ARC) program, and Dairy Margin Coverage (DMC) program. These programs would be at risk if not extended by the end of 2025.

Needs Reauthorization

• SUPPORT for Patients and Communities Act: The SUPPORT for Patients and Communities Act reauthorization lapsed Sept. 30, 2023. The updated reauthorization bill (H.R. 2483/S. 2121) recently passed the House on June 4, 2025, by a bipartisan vote of 366-57. It now awaits action in the Senate Health, Education, Labor and Pensions (HELP) Committee. The bill continues key programs aimed at preventing and treating substance use disorders, expanding treatment access and supporting recovery services. Despite broad support, some Democrats opposed the measure over concerns with the Trump administration’s broader cuts to addiction and mental health services, particularly the proposed restructuring of Substance Abuse and Mental Health Services Administration (SAMHSA) and Medicaid reforms.

• Pandemic and All-Hazards Preparedness Act (PAHPA): The PAHPA framework, which authorizes ASPR, BARDA, the Strategic National Stockpile (SNS), Hospital Preparedness Program (HPP) and the Public Health Emergency Preparedness Program (PHEP), among others, expired on Sept. 30, 2023. PAHPA has only had two comprehensive bipartisan reauthorizations since it was originally signed into law in 2006. Each new iteration added more authorizations based on new threats, technology or lessons learned. Although some PAHPA authorities were extended through Sept. 30, 2025, as part of the CR (as noted above), the comprehensive reauthorization package stalled. Both the House and Senate have advanced competing reauthorization proposals, with the House bill advancing along party lines and the Senate HELP Committee approving a more bipartisan version.

• Priority Review Voucher (PVR) Program: The PVR program, which incentivizes the development of drugs for rare pediatric diseases and other underserved conditions, was set to expire at the end of 2024. Given that Congress did not pass the EOY health care package, which included a five-year extension, the program has officially lapsed. The FDA may no longer award new vouchers for qualifying rare pediatric disease applications unless Congress reauthorizes the program. While the PVR program has strong bipartisan support and backing from patient advocacy groups, its future remains uncertain without legislative action to reinstate or extend the authority.

Further on the Horizon

Statutory Pay-As-You-Go (PAYGO) rules could trigger automatic spending cuts impacting Medicare, among other programs, if Congress does not act to offset increased deficits created by prior legislation before February 2026. This is a result of the Statutory PAYGO Act of 2010 that requires any legislation increasing the deficit to be offset by spending cuts elsewhere, or it triggers an automatic sequester. PAYGO rules provide for an across-the-board sequester of non-exempt mandatory spending when net deficit-increasing legislation is passed over the course of a year. Without enactment of legislation that would offset the deficit increase, waive the recordation of the bill’s effects on the scorecard or otherwise mitigate or eliminate the statutory requirements, the Office of Management and Budget (OMB) would be required to issue a sequestration order not more than 14 days after the end of the current session of Congress. If it was to go into effect, it would result in significant cuts to health care programs, including up to a 4% cut to Medicare reimbursements. Congress has waived PAYGO rules in previous years and we expect them to do so again, though it could bring about opposition from the more outspoken fiscal conservatives.

Looking even further ahead, the 2026 midterm elections will play a critical role in setting the tone for upcoming policy and legislative decisions. It remains to be seen how OBBB and its wide-ranging funding and programmatic cuts, including to Medicaid, will impact voters’ opinions, and whether Republicans will be able to maintain control across both chambers going into 2027.

Furthermore, we will begin to see more pieces of OBBB going into effect over the next several years. Starting in January 2027, Medicaid work requirements are scheduled to take effect, which will require states to ensure recipients meet certain employment or community engagement criteria, reshaping Medicaid eligibility and state program management. In September 2027, the Prescription Drug User Fee Act (PDUFA), the Biosimilar User Fee Act (BsUFA), the Generic Drug User Fee Amendments (GDUFA) and the Medical Device User Fee Amendments (MDUFA) will also expire. The Food and Drug Administration has begun the reauthorization process by holding a public meeting on July 14, 2025, to discuss PDUFA. By October 2027, new caps on provider taxes are expected to limit the amount states can collect, affecting health care funding and provider reimbursements. Additionally, changes in state cost sharing for the Supplemental Nutrition Assistance Program (SNAP), with a two-year delay for states with the highest payment errors, would shift states’ financial responsibilities and influence how benefits are administered.

As these policies continue to change and implementation commences, states and stakeholders will need to adapt quickly to navigate the changing environment.