With Republicans edging closer to gaining control of Congress, millions of Americans may be at risk of losing enhanced subsidies that currently underwrite the cost of health insurance bought through the Affordable Care Act’s marketplaces, according to industry experts and the Congressional Budget Office. 

The November 5 election gave control of the Senate to Republicans, while control of the House remains in limbo Monday as votes in several critical races continue to be tallied. Currently, Democrats are projected to win at least 210 House seats and Republicans 215 seats, with a party needing 218 seats in order to have the majority. 

If Republicans gain control of Congress, they are widely expected to allow the enhanced ACA subsidies to expire at the end of 2025, depriving many people who buy coverage through the ACA and who currently receive these subsidies of that financial assistance, according to health care policy experts.

So-called enhanced Affordable Care Act (ACA) subsidies, which lower the cost of health plans for millions of Americans and were passed under the Biden administration, will expire unless lawmakers renew them. During his first term in office, President-elect Donald Trump backed efforts by Republican lawmakers to repeal the ACA, but hasn’t yet revealed his plans for the program, commonly known as Obamacare, for his second term in office.

Republican House Speaker Mike Johnson said at a campaign stop last week just before the Nov. 5 election that “the ACA is so deeply ingrained, we need massive reform to make this work, and we’ve got a lot of ideas on how to do that.”

Who is eligible for enhanced ACA subsidies?

Americans with incomes over 400% of poverty — those who make just above four times the poverty level, or $103,280 for a family of four — are eligible for the enhanced ACA insurance subsidies. They also increase financial help for those who were already eligible for assistance under the ACA.

KFF, an independent health policy nonprofit, estimates the subsidies have cut premiums for eligible enrollees by 44%, or $705 annually. The organization says that if the tax credit expires, average premiums for subsidized enrollees in 12 states would at least double.

In 2024, of the 21.6 million Americans who purchased health insurance plans from ACA marketplaces, 20.1 million received enhanced subsidies, according to the CBO. 

People most at risk of losing ACA coverage if the enhanced subsidies lapse are those who live in states where health insurance premiums are particularly high, including in rural parts of the U.S. Middle-income households that depend on the enhanced subsidies could see a sharp rise in premiums, Cynthia Cox, vice president and ACA policy researcher at KFF, told CBS MoneyWatch. 

“They could go from paying no more than 8.5% of their income to easily paying 20% or more,” she said. “I imagine a lot of those folks would drop coverage.”

Without enhances subsidies, many middle income ACA Marketplace enrollees with incomes just above four times poverty would be priced out of health insurance coverage, according to Cox. 

Subsidies remain for 2025

Louise Norris, a health policy analyst at healthinsurance.org, noted that 93% of people who buy health insurance through ACA marketplaces receive enhanced subsidies. A sharp increase in their premiums would lead many to drop their coverage, leaving them uninsured, she said.

The CBO estimates that 22.8 million total Americans will enroll in ACA marketplace health insurance plans in 2025. The agency expects enrollment to drop sharply, from 22.8 million to 18.9 million, in 2026 if the subsidies are not renewed. By 2030, enrollment could dip to 15.4 million people without the enhanced subsidies. 

For now, the subsidy enhancements will remain in place through the end of 2025.

“If people are signing up now during open enrollment, their coverage will take effect in January, and it will cover them for the whole year. Their premiums won’t change — they’re good for 2025,” Norris said.

The enhanced subsidies, which were first passed in 2021 as part of the American Rescue Plan Act, will have been in place for roughly five years when they expire in 2025, or about half as long as the ACA marketplace has existed, Cox said. 

Enrollment in ACA plans has roughly doubled since the enhance subsidies have been in place, she noted, with most of that growth coming from low-income enrollees. “That’s one group you might expect to see, if they have to start making a higher premium payments, would drop their coverage,” she said. 

Making the enhanced subsidies permanent would cost $335 billion over 10 years, according to the CBO. 

Patient and consumer advocates are looking to Kamala Harris to accelerate federal efforts to help people struggling with medical debt if she prevails in next month’s presidential election.

And they see the vice president and Democratic nominee as the best hope for preserving Americans’ access to health insurance. Comprehensive coverage that limits patients’ out-of-pocket costs offers the best defense against going into debt, experts say.

The Biden administration has expanded financial protections for patients, including a landmark proposal by the Consumer Financial Protection Bureau to remove medical debt from consumer credit reports.

In 2022, President Joe Biden also signed the Inflation Reduction Act, which limits how much Medicare enrollees must pay out-of-pocket for prescription drugs, including a $35-a-month cap on insulin. And in statehouses across the country, Democrats and Republicans have been quietly working together to enact laws to rein in debt collectors.

But advocates say the federal government could do more to address a problem that burdens 100 million Americans, forcing many to take on extra work, give up their homes, and cut spending on food and other essentials.

“Biden and Harris have done more to tackle the medical debt crisis in this country than any other administration,” said Mona Shah, senior director of policy and strategy at Community Catalyst, a nonprofit that has led national efforts to strengthen protections against medical debt. “But there is more that needs to be done and should be a top priority for the next Congress and administration.”

At the same time, patient advocates fear that if former President Donald Trump wins a second term, he will weaken insurance protections by allowing states to cut their Medicaid programs or by scaling back federal aid to help Americans buy health insurance. That would put millions of people at greater risk of sinking into debt if they get sick.

In his first term, Trump and congressional Republicans in 2017 tried to repeal the Affordable Care Act, a move that independent analysts concluded would have stripped health coverage from millions of Americans and driven up costs for people with preexisting medical conditions, such as diabetes and cancer.

Trump and his GOP allies continue to attack the ACA, and the former president has said he wants to roll back the Inflation Reduction Act, which also includes aid to help low- and middle-income Americans buy health insurance.

“People will face a wave of medical debt from paying premiums and prescription drug prices,” said Anthony Wright, executive director of Families USA, a consumer group that has backed federal health protections. “Patients and the public should be concerned.”

The Trump campaign did not respond to inquiries about its health care agenda. And the former president doesn’t typically discuss health care or medical debt on the campaign trail, though he said at last month’s debate he had “concepts of a plan” to improve the ACA. Trump hasn’t offered specifics.

Harris has repeatedly pledged to protect the ACA and renew expanded subsidies for monthly insurance premiums created by the Inflation Reduction Act. That aid is slated to expire next year.

The vice president has also voiced support for more government spending to buy and retire old medical debts for patients. In recent years, a number of states and cities have purchased medical debt on behalf of their residents.

These efforts have relieved debt for hundreds of thousands of people, though many patient and consumer advocates say retiring old debt is at best a short-term solution, as patients will continue to run up bills they cannot pay without more substantive action.

“It’s a boat with a hole in it,” said Katie Berge, a lobbyist for the Leukemia & Lymphoma Society. The patient group was among more than 50 organizations that last year sent letters to the Biden administration urging federal agencies to take more aggressive steps to protect Americans from medical debt.

“Medical debt is no longer a niche issue,” said Kirsten Sloan, who works on federal policy for the American Cancer Society’s Cancer Action Network. “It is key to the economic well-being of millions of Americans.”

The Consumer Financial Protection Bureau is developing regulations that would bar medical bills from consumer credit reports, which would boost credit scores and make it easier for millions of Americans to rent an apartment, get a job, or secure a car loan.

Harris, who has called medical debt “critical to the financial health and well-being of millions of Americans,” enthusiastically backed the proposed rule. “No one should be denied access to economic opportunity simply because they experienced a medical emergency,” she said in June.

Harris’ running mate, Minnesota Gov. Tim Walz, who has said his own family struggled with medical debt when he was young, signed a state law in June cracking down on debt collection.

CFPB officials said the regulations would be finalized early next year. Trump hasn’t indicated if he’d follow through on the medical debt protections. In his first term, the CFPB did little to address medical debt, and congressional Republicans have long criticized the regulatory agency.

If Harris prevails, many consumer groups want the CFPB to crack down even further, including tightening oversight of medical credit cards and other financial products that hospitals and other medical providers have started pushing on patients. These loans lock people into interest payments on top of their medical debt.

“We are seeing a variety of new medical financial products,” said April Kuehnhoff, a senior attorney at the National Consumer Law Center. “These can raise new concerns about consumer protections, and it is critical for the CFPB and other regulators to monitor these companies.”

Some advocates want other federal agencies to get involved, as well.

This includes the mammoth Health and Human Services Department, which controls hundreds of billions of dollars through the Medicare and Medicaid programs. That money gives the federal government enormous leverage over hospitals and other medical providers.

Thus far, the Biden administration hasn’t used that leverage to tackle medical debt.

But in a potential preview of future actions, state leaders in North Carolina recently won federal approval for a medical debt initiative that will make hospitals take steps to alleviate patient debts in exchange for government aid. Harris praised the initiative.

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

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