Healthcare Vote in Congress: ACA Subsidies, Revolt, and 2026 Midterms

The healthcare votes in Congress in late 2025 and early 2026 produced two House-passed bills and no Senate action, leaving the enhanced Affordable Care Act premium subsidies expired since January 1, 2026. House Republicans passed a narrower package on December 17, 2025, focused on small-business insurance and pharmacy transparency. Three weeks later, on January 8, 2026, seventeen Republicans joined Democrats to pass a three-year extension of the lapsed ACA subsidies over Speaker Mike Johnson’s objections. Neither bill has become law. Premiums have already jumped, enrollment has dropped, and healthcare is shaping up as a central issue of the 2026 midterms.

What Expired and Who It Affected

The enhanced premium tax credits at the center of the fight were created by the American Rescue Plan Act of 2021 and extended through the Inflation Reduction Act of 2022. They expired December 31, 2025.¹ More than 22 million people were enrolled in ACA marketplace plans at the time, and roughly 93 percent of them received premium tax credits.² The credits reduced net premium costs by an average of 44 percent, or about $705 a year.³

The projections for letting them lapse were stark. The Congressional Budget Office estimated ACA Marketplace enrollment would fall from 22.8 million in 2025 to 18.9 million in 2026, and to 15.4 million by 2030. The Urban Institute estimated 4.8 million people would become uninsured in 2026, a 21 percent jump in the national uninsured population.⁴ For subsidized enrollees in the 32 states using HealthCare.gov, the average annual premium payment was projected to rise by 93 percent, with Wyoming (195 percent), West Virginia (133 percent), and Alaska (125 percent) at the top.³

Lower-income enrollees stood to lose the most in percentage terms. A 45-year-old earning $25,000 could see annual premium payments rise by an average of 573 percent. About 725,000 people earning above 400 percent of the federal poverty level faced losing their premium tax credits entirely.¹

The December 17 Republican Bill

Rather than extend the ACA subsidies, House Republican leadership advanced a different package. On December 17, 2025, the House passed the Lower Health Care Premiums for All Americans Act by 216 to 211 in a party-line vote, with Rep. Thomas Massie of Kentucky the lone Republican no.⁵

The bill focused on the employer-sponsored insurance market and small-business coverage. Its main provisions let small employers and self-employed individuals band together across industries to buy less-regulated association health plans, required pharmacy benefit managers to disclose drug rebates and fees to employers, funded cost-sharing reductions for low-income marketplace enrollees, and expanded a tax-free employer contribution mechanism known as CHOICE Arrangements.⁶ The CBO estimated the package would reduce the federal deficit by $35.6 billion over ten years and reduce the number of people with health insurance by an average of 100,000 per year. It projected the cost-sharing reduction funding would lower benchmark silver plan premiums by 11 percent on average.⁵

The bill left out the enhanced ACA premium tax credits, health savings account provisions included in competing Senate proposals, and any expansion of short-term insurance plans.⁷ Consumer groups warned that association health plans are not required to cover ACA “essential health benefits” like maternity care, prescription drugs, or mental health services, and could pull healthier consumers out of ACA-regulated markets, raising costs for those who remain.⁸

The Moderate Revolt and the Discharge Petition

Speaker Johnson’s decision to leave the ACA subsidies out was deliberate. The CBO estimated a ten-year extension would cost $350 billion, and Johnson said there was no consensus on how to pay for it. Conservative hardliners opposed extending the ACA in any form. He promised to address health insurance costs through a reconciliation package in the first quarter of 2026.⁹

That promise did not satisfy a group of vulnerable moderates. In closed-door meetings, Reps. Mike Lawler of New York and Jen Kiggans of Virginia called the refusal to hold a subsidy vote “political malpractice.”¹⁰ Rep. Brian Fitzpatrick of Pennsylvania proposed an amendment for a two-year extension with anti-fraud guardrails and income limits, but leadership expected it to be ruled out of order for lacking budget offsets.

When negotiations broke down, four Republicans signed a Democratic discharge petition to force a floor vote on a three-year extension, bypassing the Speaker: Fitzpatrick, Rep. Robert Bresnahan of Pennsylvania, Rep. Ryan Mackenzie of Pennsylvania, and Lawler.¹¹ Three of the four came from Pennsylvania, a swing state where affordability was already a central 2026 issue.

The January 8 Bipartisan Vote

The subsidies expired January 1, 2026. The discharge petition reached the floor a week later. On January 7, nine Republicans voted to advance the measure over Johnson’s objections. Joining the original four petition signers were Reps. María Elvira Salazar of Florida, Nick LaLota of New York, David Valadao of California, Thomas Kean of New Jersey, and Max Miller of Ohio.¹²

The next day, January 8, 2026, the House passed the three-year extension 230 to 196. Seventeen Republicans voted yes. Beyond the nine who supported the procedural motion, eight more Republicans crossed over: Reps. Mike Carey of Ohio, Monica De La Cruz of Texas, Andrew Garbarino of New York, Jeff Hurd of Colorado, Dave Joyce of Ohio, Zach Nunn of Iowa, Derrick Van Orden of Wisconsin, and Robert Wittman of Virginia.¹³ The CBO estimated the bill would increase the deficit by about $80.6 billion over a decade and increase the number of insured people by 100,000 in 2026, rising to 4 million by 2028.¹⁴

The Republicans who broke ranks came largely from competitive districts where rising premiums posed a direct electoral threat. Politico described them as “vulnerable House GOP moderates” reacting to “the political ramifications of allowing the subsidies to remain lapsed in the face of spiking insurance premiums in an election year.”¹² De La Cruz, the only Texas Republican targeted by national Democratic groups for 2026, said: “While this is not what we initially wanted, today’s vote is in the best interest of South Texas families and the only option to bring certainty for those who rely on these credits.”¹⁵

Why Nothing Has Been Enacted

The House-passed extension hit a wall in the Senate, where it needed 60 votes to overcome a filibuster. Senate Majority Leader John Thune signaled he would not bring it up.¹⁶ A bipartisan group of senators tried to negotiate a compromise built around a shorter two-year extension, health savings account provisions, an income cap, and language barring federal funding for abortion.¹⁷ Earlier, in December 2025, both a standalone Republican HSA proposal and a Democratic clean-extension proposal had failed.¹⁸ As of mid-2026, the Senate has passed no ACA subsidy legislation.

President Trump signed a stopgap spending bill on November 12, 2025, that excluded the subsidies, calling the ACA a “disaster” and proposing that federal money go directly to consumers rather than insurers. “I’m calling today for insurance companies not to be paid but for the money, this massive amount of money, to be paid directly to the people of our country so that they can buy their own healthcare,” he said.¹⁹ On January 15, 2026, the White House released “The Great Healthcare Plan,” a framework asking Congress to redirect subsidy payments into health savings accounts.²⁰ The Committee for a Responsible Federal Budget estimated the plan could cost up to $350 billion over ten years depending on structure.²¹ No enacted legislation followed.

Speaker Johnson’s promised first-quarter 2026 reconciliation package on health insurance costs also did not materialize. By late April, House Republicans were focused on a reconciliation bill for immigration enforcement, with healthcare deferred to a possible “Reconciliation 3.0.”²² As of June 2026, Republican leaders were still assembling a third party-line package before the August recess, with healthcare included in a broad framework but nothing finalized.²³

What It Has Cost Enrollees So Far

With the subsidies gone and no replacement enacted, the numbers moved fast. During the 2026 open enrollment period, total ACA plan selections dropped by 5 percent, or 1.2 million consumers, falling to 23.1 million. New enrollees declined by 13 percent. Rural enrollment dropped 10 percent, compared to 4 percent in non-rural areas.²⁴

Average monthly premium payments after tax credits jumped 58 percent, from $113 to $178. Average deductibles rose 37 percent to a record $3,786. Consumers shifted away from silver plans (from 57 to 43 percent of selections) toward cheaper bronze plans (from 30 to 40 percent), trading lower premiums for higher out-of-pocket exposure.²⁵ A KFF survey from early 2026 found 9 percent of 2025 marketplace enrollees had already become uninsured, and 17 percent of returning enrollees were not confident they could afford premiums for the full year.

The pain was uneven. People earning above 400 percent of the federal poverty level made up just 7 percent of 2025 enrollment but 48 percent of the drop in plan selections. Young adults aged 18 to 34 accounted for 46 percent of the total decline.²⁵ At the state level, Maryland approved an average individual market increase of 13.4 percent (partly cushioned by a new state subsidy), Washington approved 21 percent, and Arkansas, Illinois, and Indiana finalized increases above 20 percent.²⁶ The median proposed premium increase across 312 insurers was 18 percent, with insurers attributing an average of 4 percentage points directly to the subsidy expiration.²⁷

Healthcare and the 2026 Midterms

Democrats moved to make the lapse a centerpiece of their midterm strategy. DCCC Chair Suzan DelBene said: “Make no mistake, the blame behind the skyrocketing health care costs millions are facing today is squarely at the feet of House Republicans.”¹⁶ The party launched a 10-month healthcare messaging campaign with digital ads and billboards. A KFF poll from December 2025 found about three-quarters of marketplace enrollees said they would blame President Trump or congressional Republicans if subsidies lapsed.

The polling gives Democrats an edge but not a lock. A KFF survey from March 2026 found voters trusted Democrats over Republicans on healthcare costs 40 percent to 28 percent, and on prescription drug costs 38 percent to 28 percent. About two-thirds of Democratic voters and nearly half of independents said healthcare costs would have a “major impact” on their 2026 vote.²⁸ Healthcare costs ranked as the top economic concern in January 2026, with 31 percent of voters “very worried.”

Republicans are running on tax cuts from the 2025 reconciliation law and pushing back on the healthcare framing. NRCC spokesperson Mike Marinella called the Democratic push a “temper tantrum over a policy cliff of their own making.”¹⁶ Up to four in ten independents say they trust neither party on healthcare affordability, a bloc large enough to move races. With average family employer-sponsored premiums having reached nearly $27,000 in 2025 and 58 percent of voters expecting costs to grow less affordable, the issue is unlikely to fade before November.²⁸

1
Bipartisan Policy Center. Enhanced Premium Tax Credits: Who Benefits, How Much, and What Happens Next
2
Center on Budget and Policy Priorities. Five Key Changes to ACA Marketplaces Amid Uncertainty Over Premium Tax Credit
3
KFF. Inflation Reduction Act Health Insurance Subsidies: What Is Their Impact and What Would Happen if They Expire
4
Urban Institute. 4.8 Million People Will Lose Coverage in 2026 if Enhanced Premium Tax Credits Expire
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STAT News. House Passes Health Care Bill on Workplace Insurance
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House Ways and Means Committee. House Republicans Vote to Lower Health Care Costs for All Americans
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American Hospital Association. House Passes Narrow Health Care Package, Sets Vote on EPTCs for January
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Center on Budget and Policy Priorities. Association Health Plan Expansion Likely to Hurt Consumers, State Insurance Markets
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CNBC. Johnson, ACA, Republicans, Health
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Politico. Mike Johnson Confronted by GOP Moderates
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Al Jazeera. Republicans Defy House Leadership to Force Vote on Healthcare Subsidies
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Politico. House Advances Three-Year Extension of Obamacare Subsidies
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The Hill. 17 Republican Votes on Obamacare Subsidies
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PBS NewsHour. House Considers Extending ACA Subsidies After GOP Members Help Force Vote
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Texas Tribune. Texas Congress: De La Cruz Vote on ACA Extension Bill
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Politico. Democrats, Obamacare Subsidies, Midterms
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AJMC. House Votes to Extend ACA Subsidies, Eyes Turn to Senate
18
The Hill. Cassidy Optimistic on ACA Compromise
19
Healthcare Dive. Government Shutdown Ends, ACA Subsidies Not Extended
20
White House. Fact Sheet: President Donald J. Trump Calls on Congress to Enact the Great Healthcare Plan
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CRFB. White House Releases Great Healthcare Plan
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Politico. House Republicans Reconciliation Budget
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The Hill. GOP Reconciliation Bill and Midterms
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CMS. Health Insurance Exchanges 2026 Open Enrollment Report
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KFF. What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles
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Commonwealth Fund. New Federal Policies Spur Higher Health Insurance Premiums for Consumers
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Peterson-KFF Health System Tracker. How Much and Why ACA Marketplace Premiums Are Going Up in 2026
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KFF. A Preview of the Role Health Care May Play in the 2026 Election