Enhanced tax credits that have helped reduce the cost of health insurance for the vast majority of Affordable Care Act enrollees expired overnight, cementing higher health costs for millions of Americans at the start of the new year.

Democrats forced a 43-day government shutdown over the issue. Moderate Republicans called for a solution to save their 2026 political aspirations. President Donald Trump floated a way out, only to back off after conservative backlash.

In the end, no one’s efforts were enough to save the subsidies before their expiration date. A House vote expected in January could offer another chance, but success is far from guaranteed.

The change affects a diverse cross-section of Americans who don’t get their health insurance from an employer and don’t qualify for Medicaid or Medicare — a group that includes many self-employed workers, small business owners, farmers and ranchers.

It comes at the start of a high-stakes midterm election year, with affordability — including the cost of health care — topping the list of voters’ concerns.

“It really bothers me that the middle class has moved from a squeeze to a full suffocation, and they continue to just pile on and leave it up to us,” said 37-year-old single mom Katelin Provost, whose health care costs are set to jump. “I’m incredibly disappointed that there hasn’t been more action.”

Some families grapple with insurance costs that are doubling, tripling or more

The expired subsidies were first given to Affordable Care Act enrollees in 2021 as a temporary measure to help Americans get through the COVID-19 pandemic. Democrats in power at the time extended them, moving the expiration date to the start of 2026.

With the expanded subsidies, some lower-income enrollees received health care with no premiums, and high earners paid no more than 8.5% of their income. Eligibility for middle-class earners was also expanded.

On average, the more than 20 million subsidized enrollees in the Affordable Care Act program are seeing their premium costs rise by 114% in 2026, according to an analysis by the health care research nonprofit KFF.

Those surging prices come alongside an overall increase in health costs in the U.S., which are further driving up out-of-pocket costs in many plans.

Some enrollees, like Salt Lake City freelance filmmaker and adjunct professor Stan Clawson, have absorbed the extra expense. Clawson said he was paying just under $350 a month for his premiums last year, a number that will jump to nearly $500 a month this year. It’s a strain for the 49-year-old but one he’s willing to take on because he needs health insurance as someone who lives with paralysis from a spinal cord injury.

Others, like Provost, are dealing with steeper hikes. The social worker’s monthly premium payment is increasing from $85 a month to nearly $750.

Effects on enrollment remain to be seen

Health analysts have predicted the expiration of the subsidies will drive many of the 24 million total Affordable Care Act enrollees — especially younger and healthier Americans — to forgo health insurance coverage altogether.

Over time, that could make the program more expensive for the older, sicker population that remains.

An analysis conducted last September by the Urban Institute and Commonwealth Fund projected the higher premiums from expiring subsidies would prompt some 4.8 million Americans to drop coverage in 2026.

But with the window to select and change plans still ongoing until Jan. 15 in most states, the final effect on enrollment is yet to be determined.

Provost, the single mother, said she is holding out hope that Congress finds a way to revive the subsidies early in the year — but if not, she’ll drop herself off the insurance and keep it only for her four-year-old daughter. She can’t afford to pay for both of their coverage at the current price.

Months of discussion, but no relief yet

Last year, after Republicans cut more than $1 trillion in federal health care and food assistance with Trump’s big tax and spending cuts bill, Democrats repeatedly called for the subsidies to be extended. But while some Republicans in power acknowledged the issue needed to be addressed, they refused to put it to a vote until late in the year.

In December, the Senate rejected two partisan health care bills — a Democratic pitch to extend the subsidies for three more years and a Republican alternative that would instead provide Americans with health savings accounts.

In the House, four centrist Republicans broke with GOP leadership and joined forces with Democrats to force a vote that could come as soon as January on a three-year extension of the tax credits. But with the Senate already having rejected such a plan, it’s unclear whether it could get enough momentum to pass.

Meanwhile, Americans whose premiums are skyrocketing say lawmakers don’t understand what it’s really like to struggle to get by as health costs ratchet up with no relief.

Many say they want the subsidies restored alongside broader reforms to make health care more affordable for all Americans.

“Both Republicans and Democrats have been saying for years, oh, we need to fix it. Then do it,” said Chad Bruns, a 58-year-old Affordable Care Act enrollee in Wisconsin. “They need to get to the root cause, and no political party ever does that.”

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The legislation, which the Senate passed Monday night, is expected to narrowly pass the House, where Republicans hold a slim majority. House Democrats are largely anticipated to oppose the deal, which does not include a core demand: an extension to Affordable Care Act healthcare tax credits that are set to expire at the end of the year.

Speaker Mike Johnson (R-La.) said he believes the deal is poised to pass by the end of the day.

“We believe the long national nightmare will be over tonight,” Johnson told reporters in Washington. “It was completely and utterly foolish and pointless.”

House Democrats were scheduled to meet ahead of the floor vote to discuss their vote. House Minority Leader Hakeem Jeffries said Tuesday night that there is a “strong expectation” that Democrats will be “strongly opposed” to the shutdown deal when it comes to final vote.

If the tax credits lapse, premiums will more than double on average for more than 20 million Americans who use the healthcare marketplace, according to independent analysts at the research firm KFF.

The spending bill, if approved, will fund the government through Jan. 30 and reinstate federal workers who were laid off during the shutdown. It will also guarantee back pay for federal employees who were furloughed or who were working without pay during the budget impasse.

Passage of the bill would mark a crucial moment on the 43rd day of the shutdown, which left thousands of federal workers without pay, millions of Americans uncertain on whether they would receive food assistance and travelers facing delays at airports across the country.

A vote is expected to begin after 4 p.m. EST — after Johnson swears in Adelita Grijalva (D-Ariz.), who was elected seven weeks ago. Once sworn in, Grijalva is set to become the final vote needed to force a floor vote on a petition demanding the Trump administration release files connected to Jeffrey Epstein.

The swearing-in ceremony will soon lay the groundwork for a House vote that Trump has long tried to avoid. It would come as the Epstein saga was reignited on Wednesday morning when Democrats on the House Oversight Committee released new emails in which the late sex trafficker said Trump “knew about the girls” that he was victimizing.

The emails are part of a trove of documents from Epstein’s estate released to the committee.

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Trump and the GOP promise the legislation will be great for Americans.

Not everyone is celebrating.

Lost in the fiery debate over the bill’s Medicaid funding for the poor is what happens to the millions of working Americans who make too much money to qualify for the federal health insurance program.

Not everyone has employer-sponsored health insurance. Small business owners and their families, gig workers, part-time employees, and full-time workers must purchase plans on the open market if their employers don’t offer health insurance. (Companies with fewer than 50 full-time employees are not required to offer health care benefits.)

Currently, many of these residents rely on Covered California, the state’s Affordable Care Act health insurance marketplace. The program allows qualifying residents to purchase private health insurance coverage at federally subsidized rates. The program (referred to as ObamaCare) serves residents whose incomes are too high for Medi-Cal (as Medicaid is known in California).

Roughly 2 million Californians rely on Covered California for health insurance. In the Inland Empire, approximately 22,273 people were enrolled in the program during the first quarter of 2025, according to state figures.

In 2026, however, some Covered California enrollees could see their monthly premiums skyrocket.

Why?

In 2021, Congress expanded financial assistance for the Affordable Care Act. That dramatically reduced monthly health insurance premiums for Covered California enrollees by offering tax credits that can be used to offset the high costs of coverage.

However, those enhanced tax credits are set to expire at the end of 2025. The One Big Beautiful Bill did not address enhanced ACA tax credits, and it appears that Trump and the GOP do not intend to extend them.

Nationally, it’s estimated that 5.1 million people currently insured through the Affordable Care Act could lose their health coverage next year, primarily because they will be unable to afford it.

Here’s an example of how that impending expiration affects a Riverside County couple in their early 60s who own a small business and have an annual household income of $176,000.

In 2025, the couple can find health insurance plans on Covered California with premiums starting at approximately $987 per month (covers both of them). However, depending on the plan type they seek (carrier, PPO vs. HMO, low out-of-pocket costs for services, etc.), their monthly premium could be as high $4,177.

Without the enhanced tax credits, the same couple would find health insurance premiums on the Covered California marketplace to be more expensive. Based on 2025 numbers, the costs would start at $1,631 per month for a plan with a high deductible. If they want a plan with low out-of-pocket costs, they can expect to pay as much as $4,822 per month. These figures do not include the anticipated health insurance hikes expected for 2026.

For individuals with significantly lower incomes than the example above, the expected increase in health insurance costs through Covered California will be substantially greater. For example, a couple who currently earn $85,000 between them and who don’t have children or employer-sponsored health coverage are unlikely to receive any break on health insurance starting next year.

For now, they can pay as little as $342 per month for the least expensive insurance plan offered via Covered California, which features a hefty $13,000 annual deductible. Next year, that same plan could cost approximately $1,631 per month — more than a 400% increase. That’s the low end. If they want a plan that offers a lower annual deductible, they can expect to spend around $2,000 per month for the most affordable plans.

In theory, the Republican-led Congress could remedy the impending tax credit expiration before the end of the year. Given that Trump spent most of his first term in office trying to repeal the Affordable Care Act, however, the odds of that appear slim.

Stay tuned.

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The last time Donald Trump was president, his health care policies chipped away at the Affordable Care Act and helped eliminate federal abortion rights, leaving states to fill the gaps. In his second term, experts predict Trump’s agenda to be similar and warn that health care will get more expensive and harder to access for millions of people. 

Congressional Republicans, newly empowered by Trump’s victory and the Senate moving to GOP control, have made it clear that they intend to try to implement long-standing conservative goals that include decreasing government spending on health care and further dismantling abortion rights, which are currently protected in about half of the country, including California.

Newly nominated Health Secretary Robert F. Kennedy Jr. has also pushed erroneous claims about vaccine hazards and exaggerated the risks of water fluoridation that could have ripple effects across state public health efforts. 

The Democratic supermajority in the California Capitol, however, has spent the past several years passing laws to stymie future conservative administrations on health care, said Mia Bonta, chairperson of the Assembly health committee and a Democrat from Oakland. 

Legislators have protected insurance coverage of abortion and transgender care. They have expanded health insurance programs to low-income undocumented immigrants and paid for it with state funds. They have taken pieces of the Affordable Care Act and written it into state law, expanding the enrollment period and banning lifetime limits on coverage. And they’ve invested millions of dollars into public health after the system languished for a decade.

“We were able to be very deliberate in the past several years to Trump-proof our health system moving forward,” Bonta said.

Not all state lawmakers have been happy with California’s health care expansions. Senate Republican Minority Leader Brian Jones, for instance, said public insurance for undocumented immigrants, which as of this year is available to all income-eligible immigrants, is too expensive and should be “delayed or repealed entirely.”

But Democratic lawmakers and health care advocates say they are better prepared than the first time Trump took office — though they expect the new administration to put California’s new laws to the test.

“We have their playbook from 2017, and almost everything they tried to do, California helped stop through our advocacy … or through court cases,” said Rachel Linn Gish, communications director for Health Access California. “In that way we are in a much stronger position than before.”

Affordable health care at risk

During his first term, Trump tried and failed to repeal the Affordable Care Act. He has said for his second term that he has “concepts of a plan” for the program that insures more than 21 million Americans. 

Republican lawmakers in general have shifted away from talking about eliminating the program entirely, but some leaders, including Vice President-elect J.D. Vance have suggested changes that would make insurance more expensive. Vance during the campaign said he wanted to increase choices for consumers and “make the health insurance marketplace function a little bit better.”

Eliminating the health insurance marketplace, which is also known as Obamacare, has grown deeply politically unpopular even among Republican constituents. Since Trump’s first term, the number of people enrolled has grown by more than 9 million nationally. That political leverage is something that California advocates believe will help protect the program. 

“More people are enrolled in (Affordable Care Act) marketplaces than ever before,” Linn Gish said.

But in many ways the state’s Achilles heel is federal funding. Federal spending on California health care programs is more than three times greater than the state’s share. That’s more than $117 billion from the federal government to support Medi-Cal and the Affordable Care Act compared to $35 billion from California’s general fund for all state health spending, which includes public health, state hospitals and social services.

And much of California’s policies can only be fully realized with sufficient money in the bank.

With the state grappling with a third consecutive deficit next year, the most immediate and likely federal health care cut will be difficult to prevent: financial assistance for middle-class families. 

Outgoing President Joe Biden approved two rounds of Affordable Care Act subsidies during his presidency, making assistance available to middle-class families for the first time. Those  subsidies will expire at the end of 2025, and Trump and congressional Republicans have signaled that they don’t want to renew them.

Without them, premiums will increase by an average of $1,000 annually for residents with insurance through Covered California, the state’s Affordable Care Act program. Premiums are already set to increase by about 8% next year, and without federal assistance other out-of-pocket costs such as deductibles and copays will most likely spike as well. 

Prior to Biden’s push to lower health care premiums, many Californians paid upwards of 18% of their income on health insurance, according to Covered California data. Federal assistance capped that expense at 8.5%.

“You’re talking about a world where we’re doubling how much people pay,” Linn Gish said.

In 2023, California lawmakers established a backstop of state funding to help more people afford health insurance, but those reserves can’t make up the gap if federal funding stops.

Health care for immigrants

Medi-Cal, the state Medicaid program, offers expansive benefits to all low-income individuals regardless of immigration status.  The program could face uncomfortable cuts with a less-than-friendly federal administration. 

Federal dollars cover about 70% of Medi-Cal’s program costs, while the state invests approximately $30 billion in general fund spending. 

“The largest concern many of us have who have worked with our state budget is the resources we will be receiving from the federal government this upcoming year,” said Assemblymember Joaquin Arambula, a Democrat from Fresno who has focused on expansions for undocumented workers. “There are many who are struggling who need their government to help.”

About 7 million more Californians qualified for Medi-Cal after Affordable Care Act rules allowed the state to bump up income limits in 2014, and about 1.8 million undocumented immigrants have gotten Medi-Cal coverage after the state began expanding eligibility for them  in 2015.

Some California Republicans have strayed from the party platform when it comes to health care for undocumented immigrants. The Central Valley relies heavily on immigrant labor, and a handful of state Republicans from those communities supported expanded access to health insurance for undocumented residents. 

The state GOP, however, still officially opposes coverage for undocumented immigrants and several Republican lawmakers want the state to undo that health care expansion.

Gov. Gavin “Newsom and Democrat lawmakers insist on expanding free health care for illegal immigrants to the tune of $5 billion per year. In the midst of a multi-billion dollar budget deficit, hospitals and maternity wards shutting down, and a massive influx of migrants illegally crossing our open border, we should not be expanding this costly government program,” Jones, a Republican from San Diego said.

Immigrants who came to the United States in their youth and who are protected by the Obama-era program known as Deferred Action for Childhood Arrivals (DACA) for the first time can enroll in Covered California thanks to expanded eligibility under the Biden administration.

Liberal lawmakers and policy advocates hailed the expansions as a long-sought-after victory, but they remain controversial among California Republicans. Many lawmakers and advocates expect these expansions to be challenged over the next four years. 

“Anything that has Biden’s fingerprints on it is going to be the first touched. The DACA expansion is going to be high on the list,” Linn Gish said.

This year a bill expanding Covered California to all undocumented immigrants, not just those who came to the U.S. as children, stalled in committee. That measure would have allowed immigrants who make too much money to qualify for Medi-Cal to purchase insurance.

Arambula, who authored the bill, said those populations are “unjustly excluded” from buying insurance at full price even if they want to. He plans on reintroducing the measure, which could be implemented without federal approval. 

Family planning and abortion cuts

On the campaign trail Trump took credit for appointing the Supreme Court justices who ended the national right to abortion by overturning Roe vs. Wade, but he said he would not support a national law banning abortion.  

Still, California Democrats aren’t taking any chances on abortion rights. They passed more than two dozen laws to protect access to abortion, contraceptives and gender-affirming services in the last three years.

In 2022, voters also protected abortion as a right in the state constitution. 

Democratic lawmakers say they have more work to do. 

Bonta said she plans on introducing bills to further protect reproductive rights on the first day of the legislative session. Those bills would require hospitals to provide emergency abortions, protect birth control for Medi-Cal recipients and ease the regulation of birth centers. Bonta said lawmakers are working quickly and she expects many of the bills introduced in December to have urgency clauses that allow immediate implementation.

“It’s going to be a huge change within the health care space,” she said.

The first time Trump was president, he also dismantled Title X regulations that fund the federal family planning network by instituting a “gag rule” prohibiting clinics from performing or referring for abortions. The clinics funded have historically provided contraceptives, abortion care, sexually transmitted infection testing and treatment, gynecology services and postpartum care. After the rule change, the number of people served by Title X clinics dropped 60% nationally as a result of clinics exiting the program, according to the Kaiser Family Foundation, an independent health policy research center..

In California the number of people served dropped from 1 million to fewer than 200,000, said Amy Moy, co-CEO of Essential Access Health, which administers the state’s Title X money. 

California dedicated $10 million to bridge the gap, but Moy said if there is another federal cut, clinics say to expect longer wait times and fewer providers.

“We will be having to test the bounds of our guardrails and see what we can do here, but we are committed to working with partners and state leaders to do everything possible,” Moy said.

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

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In a hotel ballroom in Seattle, at fancy homes in California and at stops in Illinois and Wisconsin over the past week, Biden has been betting that reminding voters about Trump’s presidency and highlighting his Republican opponent’s latest campaign statements will work to the Democrat’s advantage.

At a Seattle fundraiser Friday night, Biden brought up Trump’s recent interview with Time magazine in which Trump said states should be left to determine whether to prosecute women for abortions or to monitor their pregnancies.

“I really urge you to read it,” Biden said.

Biden, who headlined another Seattle fundraiser Saturday before returning to the East Coast, has plenty of other Trump material to draw from, too.

The president highlights how Trump has promised, if elected, to be “a dictator on Day 1”, how he has suggested the United States would not necessarily defend allies from aggression and how he has pledged to “totally obliterate the deep state” in the federal bureaucracy, which he blames for blocking his first-term agenda.

“And he said a whole lot more,” Biden said during a Chicago appearance. “But the bad news is he means what he says. He means what he says. Unless you think I’m kidding, just think back to the 6th of January. This guy means what he says,” referring to the riot at the U.S. Capitol on Jan. 6, 2021.

Biden wants the 2024 election to be a referendum on Trump’s record and plans, but he also wants voters to look favorably on his own policies and actions.

Biden and his allies think the country needs reminding about Trump’s tenure and his outlandish and often concerning statements, particularly because the Republican is no longer ubiquitous on X, formerly Twitter, nor is he in front of television cameras as often as he once was.

“Chaos is nothing new for Trump,” Biden said in Chicago. “His presidency was chaos. Trump is trying to make the — the country forget about the dark and unsettling things that he did when he was president. Well, we’re going to not let them forget.”

Biden frequently highlights Trump’s efforts to overturn the results of the 2020 election and how he stood by when supporters violently stormed the Capitol as Congress met to certify his loss to Biden. He also points to Trump separating children from their families at the U.S.-Mexico border, tax cuts the Republican pushed through that benefited corporations and the wealthy and his repeated efforts to overturn the Affordable Care Act.

Biden’s barbs have been getting sharper of late.

He opened his Seattle fundraiser on Friday night by telling donors, “Thank you for the warm welcome. Please keep it down, because Donald Trump is sleeping. Sleepy Don.” That was a riff off of news reports that the former president has dozed off during his criminal trial in a New York courtroom. Trump has pleaded not guilty to charges in a hush money scheme to illegally influence the 2016 presidential election.

Biden also talks about Trump’s admiration for Russian President Vladimir Putin and his self-described “love letters” with Kim Jong Un, the authoritarian leader of North Korea.

Biden frequently jabs at Trump for wondering aloud during the COVID-19 pandemic whether disinfectants could be injected or ingested to fight the virus. “That bleach he didn’t inject in his body; he just put it in his hair,” Biden says to laughter every time. “But, look, he’s got more hair than I do.”

Trump’s campaign said in a statement that “their records speak for themselves. President Trump created the most secure border in history and peace in the world. President Trump was the first president in modern history not to enter the U.S. in any new wars. Joe Biden’s weakness has led to wars in Ukraine and the Middle East, an immigrant invasion of our border, anti-Semitic protests on our college campuses, and crime and chaos in every American city.”

Trump doesn’t hesitate to criticize Biden and his policies. Trump is spending much of his time lately sitting in court. But before and after the proceedings, he often stands in front of cameras outside the courtroom and goes after Biden.

At a recent Wisconsin rally, Trump mentioned Biden within the first 2½ minutes of his speech and referenced the president or his administration more than 60 times during his remarks.

Trump’s criticism often takes a dark turn. Last weekend, he told donors at his Florida resort that Biden was running a “Gestapo administration.”

The Gestapo was the secret police force of the Third Reich that squelched political opposition generally and, specifically, targeted Jewish people for arrest during the Holocaust. Trump’s unfounded comparison to Nazi-era tactics is part of his effort to deny and deflect the charges against him, most notably his effort to overturn Biden’s 2020 victory.

Biden’s strategy is a gamble. Voters are divided in their views of both men’s presidencies.

An April poll from The Associated Press-NORC Center for Public Affairs Research found that nearly half thought Trump’s presidency hurt the country on voting rights and election security, relations with foreign countries, abortion laws and climate change. But more than half of U.S. adults thought Biden’s presidency hurt the country on cost of living and immigration.

For all his criticism of Trump, Biden does get around to talking about his agenda and accomplishments. He tells supporters about his work to boost the economy and to bring the country out of the pandemic. He discusses his support for abortion rights even as he highlights how Trump has taken credit for the overturning of Roe v. Wade in part because of his Supreme Court nominations.

“Folks, the choice is clear,” Biden told supporters recently in the nation’s capital. “Donald Trump’s vision of America is one of revenge and retribution.”

“I’ve never been more optimistic about America’s chances,” he went on. “Not because I’m president, because of the state of the moment. The world needs us.”

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“President Biden promised to build on the success of the Affordable Care Act, and just one year into his Administration, we have already broken records with all-time high enrollment numbers and all-time low prices,” said HHS Secretary Xavier Becerra. “We will continue working to deliver on that promise until we make health care a right for all.” 

During the first full year of the Biden-Harris Administration, nearly 6 million new consumers signed up for coverage through the Marketplaces nationwide during the 2021 Special Enrollment Period (SEP) and this year’s Open Enrollment Period (OEP). This includes 2.8 million people who newly enrolled during the SEP and more than 3 million who newly enrolled during the OEP. Thanks to the ARP, Marketplace plans were more affordable than ever, contributing to a record-breaking 14.5 million consumers nationwide signing up for health care coverage – a 21 percent increase from last year. 

“On the 12^th Anniversary of the ACA, it is clear that the Affordable Care Act and the American Rescue Plan are working to expand access to health care coverage and have been critical to advancing health equity,” said CMS Administrator Chiquita Brooks-LaSure. “The Biden-Harris Administration’s ARP subsidies were successful and ensured that more Marketplace consumers than ever had access to quality, affordable health care and the peace of mind that comes with having health care coverage that best fits their needs.” 

A report released by the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) showed that more Americans have gained coverage during 2021, as the ARP and other Administration policies took effect. In addition, without the ARP, the average monthly premium after Advanced Premium Tax Credit (APTC) for HealthCare.gov enrollees would have been $59 per month higher, or 53 percent higher. According to a new ASPE report released today, an estimated 3.4 million Americans currently insured in the individual market would lose coverage and become uninsured if the ARP’s premium tax credit provisions are not extended beyond 2022. 

Finally, the uninsured rate fell after implementation of the ARP, the 2021 SEP, and expanded outreach efforts. The uninsured rate for the U.S. was 8.9% for the third quarter of 2021 (July – September 2021), down from 10.3% for the last quarter of 2020. 

The Biden-Harris Administration has made it a priority to continue to strengthen the ACA. President Biden is committed to building on the progress made by the ACA by reducing premiums for the millions of Americans enrolled in Marketplace coverage and closing the Medicaid coverage gap, which would lead to four million uninsured people gaining coverage. Over 18.7 million adults are now covered across 39 states (including the District of Columbia) due to Medicaid expansion, though 12 states have not expanded.  

The Biden-Harris Administration also recently announced a new SEP opportunity for low-income consumers with household incomes under 150% of the Federal Poverty Level who are eligible for premium tax credits under the ACA and ARP, which is approximately $19,000 for an individual and $40,000 for a family of four in 2022. In states that use the HealthCare.gov platform, 45% of consumers who signed up for health coverage during the 2021 SEP had household incomes under 150% of the Federal Poverty Level. This new SEP will make it easier for low-income people to enroll in Marketplace coverage throughout the year and benefit from the ARP savings.

HHS is hosting a week-long celebration of the 12-year anniversary of the ACA, from March 21 through March 25, highlighting the impact of the law and the Biden-Harris Administration’s commitment to building on its success. The theme of this week-long celebration is: “ACA: 12 Years of Advancing Health Equity for All Americans.” During the week, each day, HHS will spotlight ways in which the ACA has made gains in addressing health disparities of women and families, kids, older adults, people with disabilities, LGBTQI+ and communities of color.  

Please view the State of the ACA Report here.

To view the 2022 Open Enrollment Report, visit: https://www.cms.gov/files/document/health-insurance-exchanges-2022-open-enrollment-report-final.pdf.

 To view a comprehensive Briefing Book on the ACA, highlighting HHS reports from the past year, visit: https://aspe.hhs.gov/reports/aca-accomplishments.

 High resolution photographs are available from the recent commemoration of the 12th Anniversary of the ACA and may be accessed here: https://cmsbox.app.box.com/s/t83tnhtwk9ahg6pprgcfxow4bkl6f04m/file/934549102386.

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The biggest threat to the Affordable Care Act may not be the justices of the U.S. Supreme Court but rather the law’s biggest omission: no way to seriously control the cost of medical care. The absence of such a mechanism to curb the relentless rise in medical costs has always been the law’s Achilles’ heel, the biggest threat to its long-term stability. Ever-rising health care costs eat away at the law and jeopardize its effectiveness as a backstop for the uninsured and uninsurable. To be sure there was not much in the way of cost controls in Obamacare’s ancestral model, Romneycare, passed in Massachusetts in 2006, an omission that state is still reckoning with.

So it was not surprising that Obamacare architects didn’t strenuously push for costs control measures either in 2009. More pragmatically, they knew that doing so would have killed the already fragile deal. In the early days of Obamacare, there wasn’t much talk about what would happen if the prices of medical services continued to rise. “At the beginning we were able to serve the subsidized and unsubsidized people fairly well,” says Cathy Mahaffey, president of Common Ground Healthcare Cooperative in Brookfield, Wisconsin, one of three remaining co-ops created under the Affordable Care Act with the mission of offering a lower-priced alternative to the commercial carriers. “Affordability continues to be an issue.

This has not changed over time. We are headed in the wrong direction.” Mahaffey noted insurers have always had a “bag of tricks” they’ve been able to pull from over the years to address the rising costs of care. Those tricks have included requiring consumers to pay high out-of-pocket costs including high deductibles, cost shifting, negotiating with providers to boost patient volumes, and medical management (like encouraging flu shots), but those strategies have done little to slow the rise in costs. “At the end of the day,” she said, “We all know that health care is a business, and because of that it drives a lot of our problems today.” The result: The ACA has become a place where people who have a subsidy go to buy insurance, but, Mahaffey said, “in the unsubsidized market, we’re definitely seeing a decline.”

People who don’t receive premium tax credits are not enrolling in the ACA, she told me. Instead, a spouse with a preexisting condition might enroll in the ACA while the other might take out a short-term policy or a Christian ministry policy to lower the family’s insurance bill. To understand what Mahaffey meant, I embarked on a little shopping trip of my own across the country to see what kind of ACA policies and short-term policy alternatives are offered to buyers. I started with policies issued by Mahaffey’s co-op, which insures some 54,000 Wisconsin residents.

Although the co-ops were originally authorized to offer a cheaper alternative for consumers, I found the policies quite expensive when you consider a policy’s full real-world cost —the premium and total out of pocket costs including coinsurance, copays, and deductibles. Too many people make the mistake of looking only at the premium. Advocates, too, point to low premiums to entice people into the market while giving short shrift to the other policy elements that heap lots of costs onto policyholders. This enrollment season there have been tweets touting free bronze policies, Mahaffey told me, noting that people with incomes right around the poverty level have “multiple options for a zero-dollar bronze plan.”

But, she added, “The challenge then becomes the higher out-of-pocket costs they face with larger deductibles versus much lower deductibles in the silver plans with cost-sharing subsidies.” Five offerings, including gold, silver and one bronze plan from the co-op came with a $17,100 annual family out-of-pocket maximum, and a deductible as high as $8,550 for a single person. Even a bronze-level health savings account, which allows people to set aside tax-advantaged savings to use for medical bills and provides less coverage, came with a $14,000 out-of-pocket maximum for a family and $7,000 for an individual. Mahaffey pointed out that 87% of her co-op’s members receive tax credits to help pay their premiums, while 55% get cost-sharing subsidies.

That still leaves a whole lot of people paying full freight. The story was much the same for this hypothetical person looking for Obamacare policies in somewhat higher-cost states like California and New York, and states with lower medical costs like Oregon, Minnesota and Kentucky. High out-of-pocket maximums and deductibles were common. In California, one bronze preferred-provider plan for our 50-year old woman would cost about $832 a month, with a $6,300 deductible and an $8,200 out-of-pocket maximum. In Minnesota, a low-cost state, the monthly premium for a bronze-level preferred provider plan for a 50-year-old woman was only $364, but the yearly deductible was $6,250 and the out-of-pocket maximum was $8,550. With that kind of insurance, who can afford to get sick? What’s happened? Insurance consultant Robert Laszewski told me that “we have a program that is really bad for the middle class and really good for those with low incomes.”

People whose incomes are between 250% and 400% of the poverty level (between $31,900 and $51,040 for a single person and $65,500 to $104,800 for a family of four) get “fairly good premium subsidies. People with incomes less than 250% of poverty get great subsidies.” But those with incomes greater than 400% get no subsidies to help with premiums and the other cost sharing insurers require. That means, he said, that millions of Americans without subsidies have bailed out of Obamacare, either going uninsured as some 200,000 New Yorkers are doing because insurance is unaffordable or turning to the new market the Trump administration has created that offers short-term plans for far less money and far less coverage.

As I was researching the high costs of Obamacare policies, Kentucky Health News happened to publish one of the best insurance stories I’ve seen in a long time. The piece by Melissa Patrick clearly laid out what Anthem, the country’s second largest health insurer, has in mind for people who aren’t eligible for Obamacare subsidies. The carrier has designed a series of six policy options designed to reach a wide audience of untapped prospects, the company tells its brokers. The policies, called the “Anthem Enhanced Choice Plans” are, according to the company, “a new marketing opportunity” and “quality coverage for clients.”

It calls them budget-friendly options for people who don’t qualify for ACA subsidies. The new policies are “medically underwritten,” meaning that people with preexisting conditions will not necessarily qualify for coverage, as they would with an Obamacare policy. Anthem will scrutinize your health records. If you pass the test, you can buy coverage for as long as three years. “Anthem has positioned this to brokers as an alternative to the ACA,” says Joel Thompson, an independent broker in Ceredo, West Virginia. “When we talk to clients who don’t get a subsidy, they are suggesting ‘Enhanced Choice’ instead.” He added: “They are trying to draw off the healthy consumers from the risk pool.”

If that happens, that’s bad news for the ACA long-term. Prices will go even higher. I asked to speak to a representative from Anthem about all this, but the spokesman did not respond to my request. Anthem is well-positioned to cut into the ACA market. The company knows a thing or two about marketing slim-down policies. Before the ACA was passed, the company marketed a series of policies appealing to young adults in their 20s and 30s and older adults not yet eligible for Medicare. Policies with names like Thrill Seeker, Part-time Dare Devil, and Calculated Risk Taker came with high deductibles and high out-of-pocket limits ranging from $5,000 to $10,000. They sure sound familiar to the new short-term policies marketed today as an alternative to Obamacare. If Anthem and others ultimately succeed in moving large numbers of people out of the Obamacare risk pool and into these short-term plans, that ultimately can hurt the health law.

That’s why the danger to the ACA may not be from an adverse Supreme Court ruling but from the very structure of the law itself and the lack of cost controls. That urgently needs a reexamination in the next Congress. I’m not taking any bets it will get one. Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care column.

-Trudy Lieberman

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