Opinion: The ACA Subsidy Fight Congress Never Finished Is on Tuesday's Ballot

Open enrollment for the Affordable Care Act marketplace opens on HealthCare.gov today, November 1, two days before midterm elections that will decide which party controls Congress for the back half of President Trump's term. The timing is not a coincidence of the calendar so much as a reminder of unfinished business. A year ago this week, the enhanced premium tax credits that had made ACA coverage affordable for a record number of marketplace enrollees were allowed to lapse at the end of 2025, a decision that both parties contributed to, in different ways, and that neither has fixed since.

The result, documented in federal enrollment data and independent analyses released over the past several months, is a rare case of a policy failure showing up in the numbers before the next election rather than after it. Marketplace enrollment fell by roughly 3 million people, or about 13 percent, between 2025 and February 2026, according to a KFF analysis of federal effectuated-enrollment data, the first such drop since the first Trump administration. Subsidized enrollees who kept their coverage absorbed an average premium increase of 114 percent, from $888 a year in 2025 to $1,904 in 2026, pushing many into skimpier bronze plans with higher deductibles. Now, as 2027 open enrollment begins, insurers are not offering relief: a Peterson-KFF Health System Tracker review of filings found a median proposed rate increase of roughly 14 to 15 percent for next year, on top of 2026's increase, which was the steepest since 2018.

This is the kind of story that rarely gets the sustained attention it deserves, because it has no single dramatic moment. It is a slow leak of coverage and income, concentrated among the self-employed, early retirees, gig workers and small-business owners who buy insurance on their own rather than through an employer. It deserves attention now because the people who run Congress are about to be judged, in part, on whether they let it happen and what they plan to do about it.

How the credits lapsed

The enhanced subsidies, first enacted during the pandemic and extended through 2025 under the Inflation Reduction Act, were never permanent, and both parties knew the expiration date was coming. The fight over whether to extend them became the proximate cause of the 43-day federal shutdown that ran from October into November of 2025, and it did not end there. On December 11, 2025, the Senate took up dueling proposals: a Democratic bill to extend the credits for three years, and a Republican alternative steering the money toward health savings accounts instead. Both fell short of the 60 votes needed to advance, 51-48, and Congress adjourned for the year without a deal, letting the credits expire on schedule at the close of 2025.

The following month, House Democrats forced a vote through a discharge petition, and on January 8, 2026, the House passed H.R. 1834, the Breaking the Gridlock Act, 230-196, with 17 Republicans joining nearly every Democrat to restore the credits through 2028. It was, by design, a long shot in the Senate, where it has since sat without a floor vote. A bipartisan group of senators spent the following months negotiating a narrower compromise, built around income caps, anti-fraud provisions and a ban on "zero-dollar premium" plans that Majority Leader John Thune had set as conditions for his support, but the talks stalled, according to lawmakers involved, partly over an unrelated dispute involving abortion-related riders. No deal has reached the floor since.

Who actually pays for the standoff

The people absorbing the cost of this standoff are not abstractions. Representative Sanford Bishop, a Georgia Democrat, estimated that roughly 92,000 people in his district alone rely on the enhanced credits, a reminder that the marketplace population skews toward places, often but not exclusively Republican-leaning and rural, where employer coverage is scarcer. Federal data on the 2026 plan year show the coverage losses were not evenly distributed: states that rely on the federal HealthCare.gov platform without their own subsidy programs saw effectuated enrollment fall 15 percent, compared with a 6 percent decline in state-run marketplaces; New Mexico was the only state to fully replace the lapsed federal credits with its own subsidy, and it posted one of the smallest losses in the country. Where officials chose to backstop the federal lapse, fewer people lost coverage. Where they did not, more did.

A KFF survey of marketplace enrollees found that 73 percent worried about affording care in an emergency or hospitalization, and 44 percent said higher premiums had made it harder to afford groceries, rent or utilities. Those are the downstream effects of a 114 percent premium increase landing on people with modest, often irregular incomes just above the subsidy cliff.

"The U.S. Senate must quickly pass this bill, and the President should sign it into law," Representative Bishop said after the House vote in January, framing the extension as unfinished, not settled, business.

The case for restraint, and its limits

Republicans who opposed extending the credits unchanged do not lack an argument. The enhanced subsidies, uncapped by income, allowed some higher earners to qualify for nearly free coverage, and congressional Republicans have pointed to documented cases of improper enrollment and "zero-dollar premium" plans as evidence the program needed tighter guardrails before any extension, not after. That is a defensible position on the merits, and it is one reason the bipartisan Senate talks focused on income caps and fraud prevention rather than a simple restoration of the 2021-2025 formula. A credit that cannot be enrolled in fraudulently and that targets people who genuinely cannot afford coverage without it is a better credit than the one that expired.

The trouble is that this argument has functioned, in practice, less as a policy position than as a bargaining chip, on both sides. Republicans, who had resisted the subsidies' design since they were first enacted, let them lapse on schedule rather than negotiate a replacement in advance, then turned to a narrower bipartisan fix only after the political cost of inaction showed up in polling. Democrats, for their part, shut the government down in the name of extending the credits and did not get them extended; the shutdown ended, the credits lapsed anyway, and the subsequent House vote was less a negotiating breakthrough than a messaging exercise aimed at the very election now two days away. Neither party's tactics produced the actual outcome, continuous coverage at a stable price, that the people losing insurance say they want.

What Tuesday does and does not settle

A KFF Health Tracking Poll released in late January found 67 percent of the public, including 72 percent of independents, said Congress did "the wrong thing" in letting the credits lapse, and more than four in ten voters said health care costs would have a major effect on their congressional vote. That gives Democrats a rhetorical edge heading into Tuesday, but it is worth being skeptical that an election outcome, whichever way it breaks, automatically produces a fix. Divided government has already shown it can deadlock on this question with a shutdown as leverage; unified government of either party would still need 60 votes in the Senate to legislate anything durable, absent reconciliation maneuvers that carry their own constraints.

The Congressional Budget Office had projected, in a letter later circulated by Senator Jeanne Shaheen's office, that failing to extend the credits permanently would leave 3.7 million more people uninsured in 2027 alone; the enrollment data moving through 2026 suggest that estimate is roughly on track. What is certain is that the 2027 plan year will arrive with still-elevated premiums, a smaller risk pool skewed toward sicker enrollees who did not drop coverage, and another round of double-digit rate increases already finalized in most states. Open enrollment running through mid-January gives Congress a finite window, overlapping with the post-election lame-duck session, in which a deal would actually matter to people shopping for 2027 plans rather than simply setting up the next campaign cycle. The bipartisan framework senators were negotiating before talks stalled — caps on who qualifies, real fraud controls, no more zero-dollar loopholes, in exchange for a multi-year extension — is still sitting on the table. It does not require either party to fully capitulate. It requires both to treat a subsidy that covers millions of people's medical bills as something other than leverage. The ballots cast Tuesday will say a great deal about which party voters blame. They will not, by themselves, buy anyone a cheaper health plan in January.