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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Trump’s prime-time speech Tuesday was the latest marker in his takeover of the nation’s capital, where the Republican-led House and Senate have done little to restrain the president as he and his allies work to slash the size of the federal government and remake America’s place in the world.

The president’s address, clocking in at a record 99 minutes, added up to a defiant sales pitch for the policies that Trump promised during his campaign and leaned into during his first weeks back in office. Trump pledged to keep delivering sweeping change to rescue the nation from what he described as destruction and mistakes left by his predecessor. He seldom addressed his comments directly to the American people, who are trying to keep up with the recent upheaval, while repeatedly needling the Democratic lawmakers seated before him.

Michigan Sen. Elissa Slotkin, who delivered the Democratic response following Trump’s speech, allowed that “America wants change, but there’s a responsible way to make change and a reckless way, and we can make that change without forgetting who we are as a country and as a democracy.”

Emboldened after overcoming impeachments in his first term, outlasting criminal prosecutions in between his two administrations and getting a tight grip on the GOP-led Congress, Trump has embarked on a mission to dismantle parts of the federal government, remake the relationship with America’s allies and slap on tariffs that have sparked a North American trade war.

“It has been nothing but swift and unrelenting action,” Trump said of his opening weeks in office. “The people elected me to do the job, and I am doing it.”

Trump, who has billionaire adviser Elon Musk orchestrating his efforts to slash the size and scope of the federal government, said he is working to “reclaim democracy from this unaccountable bureaucracy” and threatened federal workers anew with firings if they resist his agenda.

Musk, who was seated in the House gallery, received a pair of standing ovations from Republicans in the chamber, as Trump exaggerated and shared false claims about alleged government abuse uncovered by the Tesla and SpaceX founder and his team of disrupters.

Trump repeated false claims that tens of millions of dead people over 100 years old are receiving Social Security payments, prompting some Democrats to shout, “Not true!” and “Those are lies!”

Trump spoke at a critical juncture in his presidency, as voters who returned him to the White House on his promise to fix inflation are instead finding economic chaos. All the gains the S&P 500 have made since Election Day are now gone, while consumer sentiment surveys show the public sees inflation as worsening.

Trump seemed prepared to double down on his trade policies, which experts have warned will raise prices for consumers.

“Whatever they tariff us, we tariff them. Whatever they tax us, we tax them,” Trump said. At the same time, he tried to ease concerns about the resulting price increases, saying, “There’ll be a little disturbance, but we’re okay with that. It won’t be much.”

Trump said one of his “very highest priorities” was to rescue the economy and offer relief to working families. He promised to organize the federal government to lower costs on eggs and energy, blaming his Democratic predecessor Joe Biden for the situation and offering scant details of his own plans.

Trump also called for the extension of his first-term tax cuts and additional federal funding for his border crackdown, including for his promised efforts at “mass deportation” of people in the U.S. illegally.

He celebrated his crackdown on migration, saying, “But it turned out that all we really needed was a new president.”

Speaking about his promised tax cuts, Trump seemed to goad Democrats, saying: “I’m sure you’re going to vote for those tax cuts. Because otherwise I don’t believe the people will ever vote you into office.”

The backdrop was the new economic uncertainty unleashed after the president opened the day by placing stiff tariffs on imports from the country’s neighbors and closest trading partners. A 25% tax on goods from Canada and Mexico went into effect early Tuesday — ostensibly to secure greater cooperation to tackle fentanyl trafficking and illegal immigration — triggering immediate retaliation and sparking fears of a wider trade war. Trump also raised tariffs on goods from China to 20%.

Republicans were boisterous as Trump stepped to the lectern in the House, chanting “USA! USA!” as the president basked in the cheers. The GOP lawmakers were jubilant, having won a trifecta of the White House, Senate and House in the elections. However, they face the challenging task of delivering on Trump’s agenda as well as avoiding a government shutdown later this month.

Across the aisle, out-of-power Democrats set the tone early, with most remaining seated without applauding or making eye contact with Trump as he was introduced in the chamber.

After several interruptions, House Speaker Mike Johnson jumped in and called for decorum to be restored in the chamber as Republicans shouted “USA” to drown out the cries from the other side of the aisle. Johnson then ordered Texas Rep. Al Green removed from the chamber.

“It’s worth it to let people know that there are some people who are going to stand up” to Trump, Green told reporters after being thrown out of the chamber.

Other Democrats held up signs criticizing like “Save Medicaid” and “Protect Veterans” during Trump’s remarks, seeking to drive public awareness to elements of Trump’s agenda they believed might offer them a pathway back to the majority.

Some Democrats chose to highlight the impact of Trump’s actions by inviting fired federal workers as guests, including a disabled veteran from Arizona, a health worker from Maryland and a forestry employee who worked on wildfire prevention in California.

Trump also used his speech to address his proposals for fostering peace in Ukraine and the Middle East, where he has unceremoniously upended the policies of the Biden administration in a matter of just weeks. On Monday, Trump ordered a freeze to U.S. military assistance to Ukraine, ending years of staunch American support for the country in fending off Russia’s invasion.

Trump recited a letter he received earlier Tuesday from Ukrainian President Volodymyr Zelenskyy, saying that the wartime president wants to come back to the table after a explosive Oval Office meeting last week broke down negotiations for a peace deal between Russia and Ukraine. “We’ve had serious discussions with Russia and have received strong signals that they are ready for peace,” Trump said. “Wouldn’t that be beautiful?”

He also announced the arrest of a suspect in the 2021 suicide bombing at the Kabul airport that killed U.S. troops during the withdrawal from Afghanistan.

Trump’s 1 hour and 39 minute speech was the longest annual address a president has ever delivered to Congress, breaking Bill Clinton’s record of 1 hour and 28 minutes.

Watching from the gallery with first lady Melania Trump were guests including 15-year-old Elliston Berry, of Aledo, Texas, who was the victim of an explicit deepfake image sent to classmates.

Other White House guests included relatives of Corey Comperatore, the former Pennsylvania fire chief who was killed as he protected his family during an assassination attempt on Trump last summer.

Republican lawmakers cheered the conclusion of Trump’s address with chants that echoed his words after he was struck in the ear by a bullet: “Fight! Fight! Fight!”

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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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