ACA

WASHINGTON — The government shutdown has reopened debate on what has been a central issue for both major political parties in the last 15 years: the future of health coverage under the Affordable Care Act.

Tax credits for people who get health insurance through the marketplaces created by the Affordable Care Act, also known as Obamacare, expire at the end of the year.

Democrats say they won’t vote to reopen the government until Republicans negotiate an extension of the expanded subsidies. Republicans say they won’t negotiate until Democrats vote to reopen the government. Lawmakers in both parties have been working on potential solutions behind the scenes, hoping that leaders will eventually start to talk, but it’s unclear if the two sides could find compromise.

As Congress circles the issue, a poll from The Associated Press-NORC Center for Public Affairs Research found that about 6 in 10 Americans are “extremely” or “very” concerned about their health costs going up in the next year. Those worries extend across age groups and include people with and without health insurance, the poll found.

A look at the subsidies that are expiring, the politics of the ACA and what Congress might do:

Enhanced premium help during the pandemic

Passed in 2010, the ACA was meant to decrease the number of uninsured people in the country and make coverage more affordable for those who don’t have private insurance. The law created state by state exchanges, some of which are run by the individual states, to try to increase the pool of the insured and bring down rates.

In 2021, when Democrats controlled Congress and the White House during the COVID-19 pandemic, they expanded premium help that was already in the law. The changes included eliminating premiums for some lower-income enrollees, ensuring that higher earners paid no more than 8.5% of their income and expanding eligibility for middle-class earners.

The expanded subsidies pushed enrollment to new levels and drove the rate of uninsured people to a historic low. This year, a record 24 million people have signed up for insurance coverage through the ACA, in large part because billions of dollars in subsidies have made the plans more affordable for many people.

If the tax credits expire, annual out-of-pocket premiums are estimated to increase by 114% — an average of $1,016 — next year, according to an analysis from KFF.

Democrats push to extend subsidies

Democrats extended those tax credits in 2022 for another three years but were not able to make them permanent. The credits are set to expire Jan. 1, with Republicans now in full control.

Lacking in power and sensing a political opportunity, Democrats used some of their only leverage and forced a government shutdown over the issue when federal funding ran out on Oct. 1. They say they won’t vote for a House-passed bill to reopen the government until Republicans give them some certainty that the subsidies will be extended.

Democrats introduced legislation in September to permanently extend the premium tax credits, but they have suggested that they are open to a shorter period.

“We need a serious negotiation,” Senate Democratic leader Chuck Schumer has repeatedly said.

Republicans try to scale the ACA back, again

The Democratic demands on health care have reignited longstanding Republican complaints about the ACA, which they have campaigned against for years and tried and failed to repeal in 2017. Many in the party say that if Congress is going to act, they want to scrap the expanded subsidies and overhaul the entire law.

The problem is not the expiring subsidies but “the cost of health care,” Republican Sen. Rick Scott of Florida said Tuesday.

In a virtual briefing Tuesday, the libertarian Cato Institute and the conservative Paragon Health Institute branded the subsidies as President Joe Biden’s “COVID credits” and claimed they’ve enabled fraudsters to sign people up for fully subsidized plans without their knowledge.

Others have pitched more modest proposals that could potentially win over some Democrats. Senate Majority Leader John Thune, R-S.D., has said he is open to extending the subsidies with changes, including lower income limits and a stop to auto-enrollment that may sign up people who don’t need the coverage.

The ACA is “in desperate need of reform,” Thune has said.

House Republicans are considering their own ideas for reforming the ACA, including proposals for phasing out the subsidies for new enrollees. And they have begun to discuss whether to combine health care reforms with a new government funding bill and send it to the Senate for consideration once they return to Washington.

“We will probably negotiate some off-ramp” to ease the transition back to pre-COVID-19 levels, said Maryland Rep. Andy Harris, the head of the conservative House Freedom Caucus, during a virtual town hall Tuesday.

Is compromise possible?

A number of Republicans want to extend the subsidies. Sen. Josh Hawley, R-Mo., said most people who are using the exchanges created by the ACA “don’t really have another option, and it’s already really, really expensive. So I think there are things we can do to reform the program.”

Hawley said he had been having conversations with other senators about what those changes could be, including proposals for income limits, which he said he sees as a “very reasonable.”

Bipartisan groups of lawmakers have been discussing the income limits and other ideas, including making the lowest-income people pay very low premiums instead of nothing. Some Republicans have advocated for that change to ensure that all enrollees are aware they have coverage and need it. Other proposals would extend the subsidies for a year or two or slowly phase them out.

It’s unclear if any of those ideas could gain traction on both sides — or any interest from the White House, where President Donald Trump has remained mostly disengaged. Despite the public stalemate, though, lawmakers are feeling increased urgency to find a solution as the Nov. 1 open enrollment date approaches.

Democratic Sen. Jeanne Shaheen of New Hampshire has been talking to lawmakers since the shutdown began, trying to find areas of compromise. On Tuesday, she suggested that Congress could also look at extending the enrollment dates for the ACA since Congress is stalled on the subsidies.

“These costs are going to affect all of us, and it’s going to affect our health care system,” she said.

Jalonick writes for the Associated Press. AP writers Lisa Mascaro and Joey Cappelletti in Washington and Ali Swenson in New York contributed to this report.

Sept. 19 (UPI) — House Republicans expect to hold a vote Friday on legislation that would fund the government through Nov. 21, but a battle over Affordable Care Act subsidies could upend the plans in the Senate.

Speaker of the House Mike Johnson, R-La., said Thursday he expects he’ll have the votes needed to pass the continuing resolution just as he did in March’s CR vote.

“We’re going to get this government funded,” he told reporters, according to NPR. “We’re going to keep the funding going and our appropriators will have more time to do their work.”

With a six-vote majority, House Republicans are likely to pass the CR, but things are less certain in the Senate, where the GOP can afford to lose only two votes.

An unnamed leader among House Republicans told The Hill that the party will attempt to force Senate Democrats into going along with the CR by refusing to return to business in Congress until Oct. 1. Congress is on a break next week in observance of Rosh Hashanah, but House Republicans have also canceled votes previously scheduled for Sept. 29 and Sept. 30.

Senate Democratic leader Chuck Schumer of New York ended up striking a deal with Republicans and voted in favor of the March CR to avoid a government shutdown at the time. He could block the bill currently under consideration with a filibuster.

Both Schumer and House Democratic leader Hakeem Jeffries of New York have promised to vote against the CR. They cited the need to extend Affordable Care Act subsidies, which are set to expire at the end of the year.

“We will not support a partisan spending bill that Republicans are trying to jam down the throats of the American people that continues to gut healthcare,” Jeffries said Tuesday.

President Donald Trump, meanwhile, expressed support for the CR on a post on Truth Social.

“Congressional Republicans, including [Senate Republican] Leader John Thune and Speaker Mike Johnson, are working on a short term “CLEAN” extension of Government Funding to stop Cryin’ Chuck Schumer from shutting down the Government,” Trump posted on his social media site.

“In times like these, Republicans have to stick TOGETHER to fight back against the Radical Left Democrat demands, and vote “YES!” on both Votes needed to pass a Clean CRP this week out of the House of Representatives. Democrats want the Government to shut down. Republicans want the Government to OPEN.”

People thinking about starting a business or retiring early — before they’re old enough for Medicare — may want to wait until November, when they can see just how much their Affordable Care Act health insurance will cost next year. Sharp increases are expected.

Premiums for ACA health plans, also known as Obamacare, on which many early retirees and small-business owners rely for coverage, are going up, partly because of policy changes advanced by the Trump administration and Congress. At the same time, more generous tax subsidies that have helped most policyholders pay for coverage are set to expire at the end of December.

After that, subsidies would return to what they were before the COVID-19 pandemic. Also being reinstated would be an income cap barring people who earn more than four times the federal poverty level from getting any tax credits to help them purchase coverage. Although Congress potentially could act to extend the credits, people weighing optional life changes should factor in the potential cost if lawmakers fail to do so.

“I would hate for people to make a big decision now and then, in a few months, realize, ‘I’m not even going to qualify for a tax credit next year,’” said Lauren Jenkins, an insurance agent whose brokerage helps people sign up for coverage in Oklahoma. “Coupled with the rate increases, that could be significant, especially for someone at or near retirement, when it could easily cost over $1,000 a month.”

Still, how things play out in the real world will vary.

The key factor is income, as the subsidy amount people receive is primarily based on household income and local insurance costs.

People experiencing the biggest dollar increase in out-of-pocket premiums next year will be those who lose subsidies altogether because they earn more than 400% of the federal poverty level. This year, that’s $62,600 for a single person and $84,600 for a couple.

This “subsidy cliff” was removed in the legislation first enacted during the COVID-19 pandemic to create enhanced subsidies, but it will be back next year if they expire. About 1.6 million people who earn more than 400% of the poverty threshold bought ACA plans this year, many of them getting some tax credits to help with the premiums, according to KFF data. KFF is a health information nonprofit that includes KFF Health News.

“A lot of small-biz owners fall around that level of income,” said David Chase, vice president of policy and advocacy for the Small Business Majority, a Washington, D.C.-based advocacy group, which is urging Congress to extend the credits.

And a good chunk of ACA enrollment consists of small-business owners or their employees because, unlike larger firms, most small businesses don’t offer group health plans.

In the Washington metropolitan area, “7 out of 10 people who qualify for lower premiums [because of the tax credits] are small-business owners,” said Mila Kofman, executive director of the DC Health Benefit Exchange Authority.

Congress must decide by the end of December whether to extend the subsidies a second time. Permanently doing so could cost taxpayers $335 billion over the next decade, but not acting could cause financial pain for policyholders and pose political repercussions for lawmakers.

Because new premiums and smaller subsidies would take effect in January, the potential fallout has some Republican lawmakers worried about the midterm elections, according to news reports.

Republican pollsters Tony Fabrizio and Bob Ward warned the GOP in a memo that extending the enhanced credits could mean the difference between success and failure in some midterm races, because support for the premium help “comes from more than two-thirds of Trump voters and three-quarters of Swing voters.”

Although supporters credit the enhanced subsidies for a record 24 million sign-ups for this year’s ACA plans, critics have blamed them for instances in which brokers or consumers engaged in improper enrollment.

“The expanded subsidies were a temporary COVID pandemic policy enacted by congressional Democrats on a party-line vote and scheduled to end after 2025,” said Brian Blase, president of the Paragon Health Institute, a conservative think tank. “They have led to tremendous fraud and waste, they reduce employer coverage, and they should be permitted to expire.”

Ed Haislmaier, a senior research fellow at the conservative Heritage Foundation, acknowledged that people earning more than 400% of the poverty level would not be happy with losing access to subsidies, but he expects most to stay enrolled because they want to avoid huge medical bills that could threaten their businesses or savings.

“They are middle-class or upper-income people who are self-employed, or early retirees with significant income, which means they have a lot of assets behind that income,” he said. “These are people who view insurance as financial protection.”

He thinks lawmakers would win political support from voters in this category by addressing two of their other major ACA concerns: that annual deductibles are too high and insurers’ networks of doctors and hospitals are too small.

“If you just give these people money by extending subsidies, it’s only addressing one of their problems, and it’s the one they are least upset about,” Haislmaier said. “That is the political dynamics of this.”

Here’s how the expiration of subsidies could play out for some hypothetical consumers.

People in households earning less than four times the poverty rate would still get subsidies — just not as generous as the current ones.

For example, those whose earnings are at the lower end of the income scale — say, just over 150% of the poverty threshold, or about $23,000 — will go from paying a national average of about $2 a month, or $24 toward coverage for the year, to $72 a month, or $864 a year, according to a KFF online calculator.

On the other end of the income spectrum, a 55-year-old Portland, Ore., couple with a household income of $85,000 would take a big hit on the cost of their benchmark plan. They currently pay about $600 a month in premiums — about 8.5% of their household income — with subsidies kicking in about $1,000 to cover the remainder.

Next year, if the tax credits expire, the same couple would not get any federal help because they earn over four times the poverty limit. They would pay the full monthly premium, with no subsidies, which would be about $1,800, based on initial 2026 premium rates filed with state regulators, said Jared Ortaliza, a policy analyst at KFF.

People should begin to see insurance rates late this fall, and certainly by Nov. 1, when the ACA’s open enrollment season begins, said Jenkins, the Oklahoma insurance agent. That gives them time to mull over whether they want to make changes in their plan — or in their lives, such as quitting a job that has health insurance or retiring early. This year, open enrollment extends to Jan. 15. Under new legislation, that open period will shorten by about a month, starting with the 2027 sign-up period.

Those who do enroll for 2026, especially the self-employed and people retiring early, should closely track their incomes during the year, she said.

It would be easy to bust through that income cap, she said.

If they do, they’ll have to pay back any tax credits they initially qualified for. Their income might rise unexpectedly during the year, for example, pushing them over the limit. An income bump could come from drawing down more money from retirement accounts than planned, landing a new customer account, or even from winning big at a casino.

“Maybe they win $5,000 at the casino, but that puts them $500 over the limit for the year,” Jenkins said. “They might have to pay back $12,000 in tax credits for winning a few thousand at the casino.”

Appleby writes for KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF, an independent source for health policy research, polling and journalism.