With Republicans edging closer to complete control of Congress, thousands of District of Columbia residents could soon face a surge in health insurance costs if the enhanced subsidies under the Affordable Care Act (ACA) expire.
The subsidies, passed in 2021 as part of the Biden administration’s American Rescue Plan, have played a critical role in reducing premiums and expanding coverage nationwide. Currently, the enhancements are only guaranteed through the end of 2025. The stakes are high for the 11,910 D.C. residents enrolled in ACA marketplace plans this year and millions across the country.
The Nov. 5 election gave Republicans control of the Senate, while the House outcome hangs in the balance as final votes are counted in critical races. Republicans hold 215 seats, while Democrats are projected at 210, leaving both parties within striking distance of the 218-seat majority. If Republicans secure the House, health policy experts warn that the ACA subsidies are unlikely to be renewed, leaving many vulnerable to steep increases in their health insurance premiums.
In D.C., where uninsured residents numbered around 17,500 in 2023—representing just 2.7% of the population, well below the national rate of 8%—the ACA has been a lifeline for many. The District’s ACA enrollment has dropped by 26% since 2020, but the potential loss of financial support could be significant for those who still rely on it.
Approximately 22% of current enrollees in the District receive an advanced premium tax credit, a form of financial assistance designed to lower monthly premium payments. If the enhanced subsidies end, many individuals could face premiums too costly to afford.
Enhanced subsidies have benefited middle-income Americans, including those with incomes above 400% of the federal poverty level (equivalent to $103,280 for a family of four). Without the subsidies, many could see their premium contributions rise from a manageable 8.5% of their income to over 20%, according to Cynthia Cox, vice president and ACA policy researcher at the Kaiser Family Foundation (KFF).
“A lot of those folks would drop coverage,” Cox remarked about the potential impact on middle-income enrollees who may struggle to sustain such costs without federal assistance.
Under the current ACA framework, 93% of those who purchase insurance through ACA marketplaces receive these enhanced subsidies. For D.C. residents and millions of other Americans, the financial support has kept insurance affordable, cutting premiums by an average of 44%, or about $705 annually, according to KFF. These credits are necessary for premiums for subsidized enrollees in high-cost states to double, making health insurance inaccessible for many.
The Congressional Budget Office (CBO) projects that if the subsidies are not renewed, total enrollment in ACA plans will drop dramatically, from 22.8 million in 2025 to 18.9 million in 2026 and further to 15.4 million by 2030. This anticipated decline would substantially shift from recent trends, where ACA enrollment nearly doubled following the 2021 subsidy enhancements. Health policy experts stress that low-income enrollees—many of whom have seen coverage expansion since the subsidy boost—are among those most likely to drop coverage if faced with higher premium costs.
With medical debt already a burden for millions of Americans, the prospect of higher health insurance costs raises additional concerns. Despite over 90% of Americans having some form of health insurance, the Kaiser Family Foundation estimates that U.S. medical debt stood at $220 billion in 2021. In the District alone, about 10,000 adults report medical debt in a given year, an issue that could be exacerbated if health insurance becomes unaffordable for those losing subsidies.
While deeply embedded in the health insurance system, the ACA has long been targeted for reform by Republican leaders. During his first term, President-elect Donald Trump, who is set to take office in January, supported Republican efforts to dismantle the ACA. Although he has yet to outline his plans for the program in his second term, House Speaker Mike Johnson recently remarked: “The ACA is so deeply ingrained, we need massive reform to make this work, and we’ve got a lot of ideas on how to do that.”
If the subsidies expire as expected, the financial strain on both low- and middle-income Americans could become a national issue.
Louise Norris, a health policy analyst at healthinsurance.org, warned that a spike in premiums would likely push many to drop their coverage, leaving them uninsured. According to the CBO, making these enhanced subsidies permanent would cost $335 billion over the next decade—a substantial figure that some argue is necessary to maintain affordable healthcare for millions.
Currently, ACA enrollees can breathe a sigh relief as open enrollment continues, with enhanced subsidies secured through 2025.
“If people are signing up now during open enrollment, their coverage will take effect in January, and it will cover them for the whole year. Their premiums won’t change—they’re good for 2025,” Norris remarked in a televised interview.