This story was adapted from an article that first published on Nov. 5, 2025.
With only two days to go before a scheduled holiday recess, it is looking increasingly likely that members of Congress will leave Washington without extending Affordable Care Act health insurance subsidies.
The enhanced subsidies for ACA marketplace plans will expire at the end of the year, spiking premiums for millions of Americans. Many are seeing the price tag of their plans double or triple.
The deadline to sign up for plans on the ACA exchange was Monday, and some subscribers say they will forgo health insurance because they can no longer afford the premiums without the subsidies.
So far, that has not spurred Congress to coalesce around a plan to address health care costs.
The Affordable Care Act may be more popular than ever. Polls show support from voters across the political spectrum for extending the enhanced subsidies, which were first passed in 2021.
But 15 years since the ACA became law, the debate over health care has endured in Congress — and seems poised to spill into 2026, when every House seat and a third of the Senate is on the ballot.
Where the subsidies debate stands
Groups of rank-and-file members on both sides of the Capitol have been trying to advance a bipartisan measure to extend the subsidies, along with some reforms.
But so far, the only measures to come up for votes have been dueling partisan measures, one backed by Senate Republicans and another from Senate Democrats. Both failed to garner enough votes.
The House is expected to vote Wednesday on a separate package of health reforms rolled out last Friday by House Speaker Mike Johnson, R-La. The narrow measure wraps together a handful of longstanding ideas favored by conservatives, like association health plans. But as with the GOP bill that failed in the Senate, the House package would not extend the expiring subsidies.
Top Democrats in the House have continued to insist on the same plan tried by Democrats in the Senate: a standalone three-year extension, without any reforms that could help entice enough Republicans.
Four Senate Republicans voted with Democrats on that bill: Susan Collins of Maine, Alaska's Lisa Murkowski and Dan Sullivan, and Josh Hawley of Missouri.
"I do know the effect on people at home," Hawley told NPR after the Senate vote. "Right now, people at home are saying we need our health care prices to be lower. So I'm doing everything that will help lower the cost of health care."
Why some Obamacare critics want to extend subsidies
Democrats spent the fall trying to force an extension of the subsidies. For weeks, they withheld their votes on legislation to fund the government, resulting in a record-long shutdown. Even some Republicans warned against letting the enhanced subsidies expire.
"Twenty-two million people shouldn't be forced to pay the price for congressional inaction," Rep. Kevin Kiley, R-Calif., told NPR this week. "We're talking about small business owners and their employees, independent contractors, gig workers, early retirees who'll be forced to pay a price that many simply can't afford."
About a dozen House Republicans have signed on to a pair of proposals to maneuver around leadership to force a vote on extending the subsidies. It is not clear whether either could attract enough support. Even if they did, it is very unlikely they would receive a vote before the subsidies expire.
Even the conservative firebrand Rep. Marjorie Taylor Greene, R-Ga., has called for keeping the subsidies, despite sharp criticism of Obamacare, saying the cost of health care is a top issue in her deep red district.
"The toothpaste (Obamacare - ACA) is out of the tube," Greene wrote on X in October.
When the ACA passed with no Republican votes, this acceptance would have been hard to imagine.
Fights over the ACA helped fuel a 2013 shutdown. Sen. Ted Cruz, R-Texas, held the Senate floor for more than 21 hours, railing against Obamacare and memorably reading from Dr. Seuss' Green Eggs and Ham.
Former Republican House Majority Leader Eric Cantor says backlash against the law helped give rise to the Tea Party and later the Make America Great Again movement.
"There was a lot of trepidation as to what Obamacare was going to mean," Cantor told NPR. "Whether you were going to be able to keep your doctor, whether there were going to be 'death panels,' and honestly a concern about the unknown."
Over the years, Republicans repeatedly tried to repeal and replace Obamacare, but now many acknowledge that it is here to stay.
"We still faced opposition from within our own ranks," said former Rep. Fred Upton, R-Mich., who chaired a key committee that tried to work on a substitute. "Here we are today, and there's still no alternative. It's been 15 years. It's not gonna go away."
Johnson has traded the refrain "Repeal and Replace" for a new one: "Reduce and Repair."
"The roots of Obamacare, the Unaffordable Care Act, have gotten so deep in the system that it's no longer possible to just pull it out at the root and chop it off and start over," Johnson told reporters on Tuesday. "It's too deeply ingrained, so now we have to take it step by step, to reduce and repair — reduce costs and repair the system."
But for months, Johnson and other Republicans, including President Trump, who talked about "concepts of a plan" to replace the ACA during a debate last fall, struggled to articulate concrete reforms.
"It's been hastily thrown together," Kiley said of the GOP legislation up for a vote on Wednesday. "It doesn't address the immediate crisis in front of us."
Polls show a majority of Republicans still oppose Obamacare, but the law's popularity has grown, says Ashley Kirzinger, director of survey methodology at the health policy organization KFF. More than half of marketplace enrollees live in Republican congressional districts.
"They're more likely to live in rural areas, to own a small business or be farmers," she said.
An October survey of competitive congressional districts by Republican pollster John McLaughlin, who has worked with Trump during each of his campaigns, also found overwhelming support for extending the subsidies. He says the results have been put in front of top advisers at the White House.
"Voters are definitely more likely to vote for somebody who's gonna support a health care tax credit that they can use versus those who might oppose it," McLaughlin said in an October interview.
Why top Republicans are pushing back against the subsidies
Some Democrats hoped Trump would cut a deal on subsidies. But Trump has continued to bash Obamacare and has yet to embrace an extension.
And many rank-and-file Republicans remain skeptical of the ACA, including Sen. Bill Cassidy, R-La., a gastroenterologist, who helped craft the Senate GOP health plan that failed last week.
"Obamacare has become the 'Unaffordable Care Act,'" Cassidy said in October. "And the reforms that were supposed to lower costs are now being papered over with more and more subsidies."
Cassidy's plan would have deposited up to $1,500 annually in health savings accounts for people making up to 700% of the federal poverty line with high-deductible ACA plans. The money could be used for expenses like copays and medicine, but not for premiums.
"Who gets the money? The insurance companies," Cassidy said last week of the enhanced subsidies. "Under our program, the patients and the families get it."
In the House, Republican leadership squashed an effort by moderates to tack onto the GOP bill a vote to extend the subsidies.
Rep. Jeff Hurd, R-Colo., one of the moderates who has called for extending the subsidies, agrees the subsidies only address a symptom of the ballooning cost of health care. Still, he says extending them is an imperative — and hopes this can be an opportunity for a bipartisan conversation about health care.
"Whether it's something they're public about or not, if you're genuinely serious about serving your constituents, this ought to be something on your radar screen," Hurd said in October.
Why Democrats are all-in on their health care push
Democrats bet enormous political capital as they held out for a subsidies deal, emboldened by 2018, when candidates running on health care helped sweep the party back into the House majority.
That year, Democrat Andy Kim ran for a Republican-held congressional district in New Jersey. The incumbent, Rep. Tom MacArthur, was a key player in efforts to repeal and replace Obamacare, authoring an amendment that would have allowed states to waive the ACA ban on denying coverage over pre-existing conditions.
"Everyone was furious," Kim recalled in October. "He really touched a third rail."
That year in Michigan, Democrat Elissa Slotkin also challenged a Republican incumbent on health care.
"I think it was the dominant issue," Slotkin said. "My experience with my mom not having insurance when she was diagnosed with Stage 4 ovarian cancer just meant that a lot of people wanted to talk about it and I had a lot to say."
Kim and Slotkin won their races — part of a blue wave that gave Democrats control of the House. Eight years later, they are in the Senate, where Democrats refused to back a stopgap spending bill without a deal to extend expiring ACA subsidies.
"You're talking about people who are going to be doubling their costs and then therefore deciding not to keep health care coverage," Slotkin said.
Ultimately, a handful of Democratic senators relented, voting last month to reopen the government in exchange for the promise of a vote on extending the health subsidies.
"I think what's really telling is that we see not just majorities, but large majorities, of Republicans, independents and Democrats saying that they want Congress to extend the enhanced premium tax credits," KFF's Kirzinger said.
KFF has been polling on the ACA for years. The 2010 law is more popular than ever, a sea change from 15 years ago, when Americans were more evenly divided on the law.
"The best thing that happened to the Affordable Care Act politically was when Republicans started trying to take it away," said Meredith Kelly, a top Democratic congressional committee staffer during the 2018 midterms.
Leading up to that cycle, Kelly worried that Obamacare was a political liability for Democratic candidates. But then, with Trump in office, Republicans moved to destroy it.
"I think that the 2018 cycle was a massive turning point for the popularity of the ACA," Kelly said. "And I think that's in great part because Democrats worked really hard that cycle to help Americans understand what Republicans were ripping away."
If Republicans decline to back a plan to extend the subsidies, many Democrats think that will give them a powerful message in next year's midterm elections.
Hustling to a vote in October, Slotkin said she did not know whether health care will play the same driving role it did in 2018. But she says there is reason to believe it will.
"Among all of the major ways people are paying more and the cost of living is going up, I can't think of something that is more personal than health care," she said.
What's next for the subsidies debate
The House is expected to vote Wednesday on the health care bill backed by Speaker Johnson, which does not address the subsidies.
Some lawmakers hope the failed partisan votes will recharge efforts to find a bipartisan compromise.
"You can't get something done until you get started," Murkowski said after the failed votes last Thursday. "And so what we did today is we demonstrated what we can't do."
But lawmakers are set to leave town soon — and with new premium rates set to take effect in less than two weeks, the time for a deal to stave off those price spikes seems to be running out.
More on the debate in Congress over health care
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