Health insurance could be about to get a lot more expensive for millions of Americans, and that’s posing a political challenge for U.S. President Donald Trump.
That challenge comes from two conflicting fundamentals underpinning his presidency: his promise to make life more affordable for Americans and his determination to tear down any affordability measures established by the last two Democratic presidents, Joe Biden and Barack Obama.
That conflict hits its peak with the Affordable Care Act (ACA), the program colloquially known as Obamacare.
Enhanced tax credits introduced in 2021 under Biden, which brought down the cost of ACA premiums for roughly 24 million people, are due to expire on Dec. 31. The end of the credits — often described as subsidies — will result in the average premium more than doubling, according to an analysis by KFF, an independent health policy organization.
A family of four with a household income of $75,000, roughly in the middle of the U.S. annual earnings spectrum, would see annual premiums jump from $2,498 to $5,865, according to the analysis.
By some estimates, it’s leaving millions of Americans facing the prospect of giving up their health insurance altogether.
Lori Hunt, a breast cancer survivor in Iowa recently laid off from her administrative job at a non-profit, faces a $650 US increase in her monthly payment to keep her existing policy.
“That’s just about as much as my mortgage,” Hunt said in an interview from her home in Des Moines. “Right now, that is not in my budget. That is not anything I can afford.”
Hunt says her only options are to switch to a plan with less coverage or higher deductibles, or to go without health insurance until she finds a job that provides it.
“It’s just a gamble and I hate it,” she said. “I’d have to just kind of hope for the best.”
Senate to vote on extending subsidies
The hope that remains for Hunt and others in her situation, albeit faint, is that the Republican-controlled Congress agrees to some kind of extension of the enhanced ACA subsidies.
The ACA was designed to cover the millions of people who don’t have employer-paid health insurance, but don’t qualify for Medicare because they’re not seniors, or for Medicaid because they’re not living in poverty. Typically, they’re self-employed, underemployed, or retired before 65.
The fate of the subsidies was central to the Democrats’ move to trigger this fall’s record-long government shutdown. It ended when Senate Republicans agreed to hold a vote on extending the subsidies — a vote likely to take place next week, but with no guarantee of success.
Meanwhile, Trump is floating his own idea that he claims would tackle rising health-care premiums. His idea would also deal a crippling blow to Obamacare, a program he tried to eliminate from the start of his first term. That push failed when Republicans in Congress balked because the ACA was benefitting many of their voters.
At a cabinet meeting, U.S. President Donald Trump disparaged Obamacare, the subsidized health-insurance program formally known as the Affordable Care Act, created during then-president Barack Obama’s first term. Trump called the program a ‘disaster’ and floated his own idea for an alternative.
This term, Trump is floating a wholesale change to the system that he pitches as moving government-funded subsidies away from health insurance corporations.
“Obamacare is a disaster. I said it years ago and I say it now,” Trump said Tuesday during a televised meeting of his cabinet. “Obamacare was made to make the insurance companies rich.”
Trump said he instead wants “the money to go to the people … and that the people go out and buy their own health care.”
He even has a name for this system: “Call it Trumpcare,” he said in an interview on Fox News in November.
Trump hasn’t given many more details of what the system would look like, but there is already concern it would not provide Americans with the coverage they need.
“These proposals that Donald Trump is floating are nothing short of just sabotaging the Affordable Care Act,” said Maddie Twomey, with the advocacy group Protect Our Care, in an interview from Boston.
Twomey says withdrawing the subsidies would undermine the whole premise of how the ACA works, in that it removes certain guarantees of coverage.
For example, insurance companies are not permitted to deny anyone coverage for having a history of illness, while the system attracts a big enough pool of relatively healthy people that it lowers the risk to insurers.
“Donald Trump likes the idea of pushing people into junk insurance plans that don’t cover pre-existing conditions, that might not provide essential health benefits like hospitalization, maternity care,” Twomey said.
Over 4 million could lose health insurance
ACA premiums grabbed attention this fall as the renewal period for 2026 began and people saw the sharp rise for themselves.
“It’s an all-out attack on our health care and it’s going to be catastrophic,” Twomey said, pointing to estimates suggesting millions of people will go without insurance if the subsidies expire.
The Urban Institute policy organization projects 4.8 million more people will be uninsured in 2026 if the enhanced tax credits are not extended.
The non-partisan Congressional Budget Office puts the figure at 4.2 million. It also estimates the subsidies, if made permanent, would cost the Treasury $350 billion US over the next 10 years.
The debate over the ACA subsidies comes at a time when the results of recent elections in New Jersey, Virginia and New York City suggest affordability is a top political concern in the U.S.
In an October poll by Reuters and Ipsos, more respondents picked cost of living over any other issue as the top factor in how they will decide to vote in next year’s midterm elections, which will determine whether the Republicans retain control of Congress.
The expense voters want politicians to address the most, according to that poll, is health care.
In Iowa, Lori Hunt is counting on that voter sentiment to sway her Republican representative toward supporting the ACA subsidies.
“My congressman came out and said, ‘Oh, I’m kind of in favour of extending the ACA credits,'” Hunt said. “But talk is cheap, and I really need him to get on it and do it.”
