Health Insurance for 20 Million is at Risk

If Congress fails to extend the enhanced Affordable Care Act (ACA) subsidies, which the Senate will vote on again this afternoon (Thursday, December 11), the number of people without health insurance will increase on January 1 and the out-of-pocket cost for those who are still be able to purchase health care insurance through the ACA will skyrocket.

After weathering the longest government shutdown in history earlier this year, you might be left thinking that the price tag for the enhanced subsidies for the ACA has got to be huge. Why else would the Republican Congress shut down the government rather than agree to sign a bill that would have extended the enhanced subsidies for two years?

But it’s not huge, especially for this Congress. Extending the enhanced ACA subsidies for two years would cost the federal government $60 billion. That’s far less than the $116.6 billion tax cut that will go to the richest 1% (with incomes of $916,900 or more) in 2026, as part of Trump’s Big Beautiful Bill, which Congress approved over the summer. And the House passed a $900 billion defense policy bill just yesterday. 

ACA at an Impasse

The ACA, also known as Obamacare, was enacted in 2014. The insurance plans available on the ACA marketplace limit deductibles and also place a limit on annual out-of-pocket spending. The enrollees make payments to insurance companies for coverage, but federal government subsidies reduce their premiums. The subsidies work on a sliding scale geared to the income and family size of an enrollee. 

The ACA subsidies play a vital role in U.S. health care supports. ACA subsidies go overwhelmingly to low-income and moderate-income households that are not eligible for Medicaid (health care for the poor) or Medicare (health care for the elderly) and not covered by an employer-based health insurance plan. The ACA enrolls people in households with incomes greater than the federal poverty line, but less than four times the federal poverty line. In 2025, those income limits for individuals ranged from $15,650 to $62,600 and from $32,150 to $128,600 for a family of four.

ACA subsidies, the original and enhanced subsidies combined, cost $111.2 billion in Fiscal Year 2024 (October 2023 to September 2024). That fiscal year the federal government spent more than seven times as much on Medicare, more than five times as much on Medicaid, and more than three times as much on the tax loophole that allows employer contributions to health care coverage to go untaxed.

In 2021, following the Covid-19 pandemic, Congress increased the ACA marketplace subsidies and then extended those additional benefits to the end of 2025. It is those enhanced benefits that are set to expire a few weeks from now, at the end of the year. 

With the enhanced benefits in place, the number of people who were able to obtain health care coverage through the ACA marketplace more than doubled, from 11.2 million in February 2021 to 23.4 million in February 2025. And with the expansion of the ACA marketplace and the introduction of continuous (unchanged from one calendar year to the next) enrollment, which kept enrollees on Medicaid, the number of uninsured dropped by 4.4 million people. In 2024, 8.2% of the population was uninsured in 2024, down from 9.7% in 2020. Black adults and Hispanic adults continued to go without health insurance at a rate two and three times higher than 8.2%. If Congress fails to renew the ACA enhanced benefits, that progress will be reversed, and that says nothing of the additional 10 million people likely to lose their health insurance because of provisions in Trump’s Big Beautiful Bill.

Most—some 63%—of the enhanced ACA spending went to lower income enrollees with household incomes under $100,000. And the enhanced benefits eliminated the premium payments for households with income below 150% of the poverty level. Nonetheless, enhanced ACA subsidies went to 93% of current enrollees.  That includes a relatively small number of new enrollees, usually older adults (50 to 64) and the self -employed (usually small business owners), with household income above four times the poverty level who spent more than 8.5% of their income on health insurance premiums.

Failing to renew the enhanced benefits will hit those lower-income ACA enrollees especially hard. A recent report from the Center for Budget and Policy Priorities makes that clear:

The premiums paid by a family of four with an income of $43,000 in 2024 (143% of the poverty line) would go from $0 to $1,729 a year. 

The premiums for an individual making $32,000 in 2024 (204% of the poverty line) would increase from $696 to $2,160 a year.

The premiums for a couple making $44,000 in 2024 (208% of the poverty line) would increase from $1,020 to $3,036 a year. 

Premiums for enrollees with higher incomes would also increase dramatically, but not as quickly as those of lower-income enrollees.

Without the enhanced ACA subsidies, enrollees’ premiums would more than double on average, pushing people out of the ACA marketplace, and adding 3.8 million people to the uninsured by 2035, according to the Congressional Budget Office. The number of enrollees who would actually lose their health insurance could be even higher. In a recent survey conducted by the Kaiser Family Foundation, one in four ACA marketplace enrollees said they would “very likely” go without insurance if their premium payments doubled. That would be more than 5 million people.

What to Do?

“A clean extension would be the best outcome” says Jennifer Sullivan, the director of Health Coverage Access at the Center for Budget and Policy Priorities. With over 20 million enrollees dependent on ACA enhanced subsidies to able to afford health insurance, she is right. It is the only option Congress would be able to enact before the extended benefits expire at the end of the year. The cost of a clean extension would cost $350 billion over the next decade, about one-tenth of the cost of Trump’s Big Beautiful Bill. And it would still cost far less than the cost of the tax breaks that the bill will shower on the richest 1% over the next decade.

But more fundamental change is in order. Universal health care coverage, a single-payer system that skips over the insurance industry, would not only insure the uninsured but also reduce health care costs. And guaranteeing health care coverage regardless of employment status or income would empower workers and those looking for work, who would no longer be dependent upon their employers for health care coverage. 

John Miller is a professor emeritus of economics at Wheaton College and a member of the Dollars & Sense collective.