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The Role of ACA
For the last 15 years, the Affordable Care Act (ACA), a central pillar of the American healthcare system, has provided millions of Americans with access to affordable health coverage. Obamacare, as it’s informally known, allows individuals to purchase insurance through marketplaces and protects more than 100 million people with pre-existing conditions from being denied coverage by insurance companies.
The law has faced persistent opposition from Republicans. During his first term, the Trump administration sought to weaken or dismantle the ACA through repeal-and-replace efforts and lawsuits. They implemented administrative actions to curtail its effectiveness by cutting funding for public outreach, limiting enrollment periods, and promoting alternatives that bypassed ACA regulations.
In 2017, the ACA narrowly survived repeal when the late Senator McCain cast the decisive vote in the Senate against its dismantling. Now in his second term, Trump has renewed efforts to roll back key ACA provisions.
The “One Big Beautiful Bill” – Implications
In June 2025, the House of Representatives passed H.R.1, the Budget Reconciliation Act of 2025, also called the “One Big Beautiful Bill” (OBBB), which made significant changes to ACA marketplaces, impacting millions of Americans who are small business owners, self-employed workers, gig economy participants, and hourly wage earners. It also made funding cuts to Medicaid and SNAP (the Supplemental Nutrition Assistance Program.
Instead, the OBBB prioritized tax cuts for the ultra-wealthy, increased funding for immigration enforcement and defense funding, and advanced fossil fuel subsidies.
The Congressional Budget Office (CBO) H.R.1 projections expect the national debt to increase by $687 billion over the 2025-2034 period, pushing the cumulative deficit to approximately $4.5 trillion. Despite these fiscal consequences, Republicans pushed for their agenda and declined to extend the enhanced ACA tax credits, citing concerns over the ballooning national debt.
Shutdown & the ACA
The federal government shut down two weeks ago, following a budget stalemate between the Republicans and the Democrats in Congress over the future of ACA tax credits, which are scheduled to expire at the end of December 2025. The Democratic leadership wants to make these tax credits permanent, rejecting short-term fixes that would merely postpone the problem.
At an October 10 briefing hosted by the American Community Media, health policy experts discussed the implications of the shutdown on ACA operations and enrollment.
In 2025, over 24 million people enrolled through the ACA marketplaces; 90% received federal tax credits, which substantially reduced their monthly premiums (the amount varies based on income level). The Biden administration introduced these enhanced credits in 2021 to expand eligibility and increase the value of the subsidies. However, the OBBB undermines certain provisions with measures that:
- eliminate automatic re-enrollment for those receiving premium tax credits, requiring annual re-verification of eligibility.
- shorten the open enrollment period, making it harder for individuals to sign up on time.
- remove the repayment cap, forcing enrollees to return larger sums to the government if their income changes during the year.
- collectively erode the accessibility and stability of ACA coverage.
Premiums will skyrocket in 2026
Roughly half the American population gets insurance coverage through their employers, said Anthony Wright, Executive Director at Families USA, while public programs like Medicaid and Medicare cover one-quarter to one-third of Americans. The remainder – millions of individuals and families rely on ACA marketplaces. Wright emphasized that Congress must act before November 1 when the next open enrollment period begins, to renew enhanced tax credits or insurance premiums will rise dramatically, placing coverage out of reach for many.
Wright warned, “The Congressional Budget Office estimates that 1.5 million people may opt not to get coverage, just from the sticker shock, when they see what the new premiums are going to be!” If Congress fails to act, potential enrollees will immediately encounter higher quoted premiums, which may deter them from signing up – even if lawmakers later restore the credits before year’s end.
The nonpartisan Kaiser Family Foundation (KFF) estimates that if these tax credits expire, average premiums could rise by 114% or even double for some in 2026, forcing people to drop their health insurance entirely; at least 4 million people could become uninsured in the next few years, warns the Congressional Budget Office, if these enhanced tax credits expire.
Working class Americans hit the hardest
Jenny Sullivan of the Center for Budget and Policy Priorities, said, “93% of marketplace enrollees currently receive premium tax credits (PTCs).” Sullivan noted that the enhanced tax credits – originally introduced during the height of COVID-19 pandemic under the American Rescue Plan Act and later extended by the Inflation Reduction Act – reduced average premiums by 44%.
This change led to a sharp rise in enrollment, particularly among historically uninsured groups, including Black and Latino communities, low-income individuals, and residents of states that had not opted for Medicaid expansion. In these states, enhanced tax credits often represent the only path to affordable coverage.
Sullivan explained that these credits are available to those earning more than four times the federal poverty level, if their premiums exceed a high percentage of income. Nonetheless, about 90% of marketplace enrollees earn below this threshold, and nearly half earn less than twice the poverty level, underscoring the ACA’s importance for working-class Americans.
Most enrollees live in Red States
KFF data shows that 75% of the enrollees who rely on HealthCare.gov or ACA marketplaces reside in states that President Trump won in 2024. The ACA was designed with a dual system – Medicaid for the poorest and subsidies for those on slightly higher incomes.
However, many low-income residents in states that declined to expand Medicaid rely exclusively on marketplace subsidies for healthcare access, leading to disproportionately high enrollment in Tennessee, Georgia, Mississippi, Louisiana, West Virginia, and Texas; marketplace enrollment in these red states has tripled since the law’s inception. Only West Virginia and Louisiana among these six states opted to expand Medicaid.
Broad Public Support for Extending Tax Credits
A KFF poll found that 78% of Americans favor continuing the premium tax credits beyond 2025, said Ashley Kirzinger, KFF’s director of survey methodology. ““92% Democrats, 82% of Independents and 59% of Republicans are in favor of this extension.” Even among self-identified MAGA supporters, 57% agree that these subsidies should be continued, she added.
The broad public support for extending tax credits has prompted Republicans in difficult reelection races to reconsider their stance in September 2025, with 11 GOP House members endorsing H.R. 5145, a bipartisan proposal to extend the subsidies through 2026, effectively deferring the issue until after the midterm elections. The bill has yet to be brought to a vote. On X, GOP leader Marjorie Taylor Greene of Georgia publicly expressed support for the extension posting, “I’m absolutely disgusted that health insurance premiums will DOUBLE if the tax credits expire this year.”
What’s next?
Without congressional action before November 1, millions could face unaffordable premium hikes during open enrollment, risking a reversal of coverage gains achieved over the past decade.
Advocates at the briefing encouraged citizens, advocacy groups, and healthcare organizations to contact their representatives, raise public awareness, and participate in outreach campaigns highlighting the human and economic cost of letting tax credits lapse. They urged policymakers to weigh short-term fiscal arguments against the long-term social and economic stability that universal, affordable healthcare provides.
The Affordable Healthcare Act is not just a landmark healthcare reform but a barometer of political will and compassion in the United States on whether access to healthcare is a privilege or a right.
This article was written with support from the American Community Media Fellowship Program.