Why 4 million people could lose healthcare if Republicans don’t step up
By Michael Jones
First, Republicans passed deep cuts to Medicaid. Now, millions more could lose their health insurance altogether.
That’s the reality facing low- and middle-income families as a pair of looming policy changes—one enacted, one impending—threaten to rip through the nation’s safety net.
The Republican reconciliation bill signed into law earlier this month will remove millions from Medicaid through steep cuts and new eligibility restrictions. And now, yet another threat is on the horizon: The expiration of enhanced premium tax credits under the Affordable Care Act, which helped more than 24 million people afford health coverage. Without congressional action by December 31, an estimated 4.2 million Americans could be entirely priced out of their plans.
Rep. Lauren Underwood of Illinois, a top House Democrat and one of Congress’s most vocal health care champions, is working to stop that from happening. She wrote the legislation that created the tax credits, and now she’s leading the push to extend them before the end of the year while warning that inaction would force Americans to choose between affording coverage or going without care altogether.
The four-term congresswoman told me last week that lawmakers are actively negotiating legislation to prevent the looming expiration of federal subsidies known as enhanced premium tax credits that help millions of Americans afford health insurance through the ACA marketplace. But the clock is ticking.
“We’re working on it,” she said when I asked whether an extension could realistically pass by year’s end.
Underwood, who authored the Health Care Affordability Act that became part of the Inflation Reduction Act, is sounding the alarm over what she sees as preventable harm. Without congressional action, she warned, Americans could see their monthly premiums spike from less than $10 to more than $125.
“We heard from insurance companies last week. Like in Illinois, Blue Cross Blue Shield, which is our biggest provider in the marketplace, is increasing premiums by 27 percent,” she said. “So what that means is, if you had a tax credit, you’re paying like $8 or $9 a month. Your actual premium might be $100. So now it’s increased by 27 percent. You went from $8 a month to $127 a month.”
She said that kind of jump would push many families out of the marketplace altogether, with devastating consequences.
“That’s not affordable for a lot of people. And then they end up uninsured. And then what happens? They can’t get their medicine, they can’t see their doc, they can’t get a procedure they need. People die.”
Democrats argue that the expiration of the ACA tax credits is part of a sweeping rollback of federal health care policy under Trump 2.0 and the new Republican majority. The reconciliation bill signed into law on July 4 included deep Medicaid cuts and the elimination of ACA premium tax credits, making coverage more affordable for millions of Americans. Insurers are already finalizing 2026 rates, and the early signs are bleak: base premiums are rising by an average of 15 percent, according to KFF, and many families losing their tax credits could face premium hikes as high as 75 percent.
More cuts and restrictions are coming. At the end of August, the Trump administration will impose new ACA enrollment rules that shorten sign-up windows and increase red tape to shrink the number of people with coverage. In 2026, states will begin implementing new six-month Medicaid eligibility checks and coverage reapplications that health care experts say will lead to millions of Americans, including children, being pushed off the rolls. By 2027, the Medicaid coverage losses are expected to skyrocket, and new restrictions on Medicare eligibility could leave elderly immigrants without care, even those who’ve paid into the system for years.
Republicans are also making it easier for insurers to offer lower-quality plans and harder for people to access tax credits and enrollment assistance. Meanwhile, a $5 billion pharmaceutical industry giveaway will take effect in 2028 by allowing drug companies to sidestep Medicare price negotiations.
When Congress returns from the August recess, it faces a condensed fall calendar dominated by must-pass legislation, including annual government funding bills and the National Defense Authorization Act. Floor time will be limited, and partisan tensions will remain high as Republican lawmakers remain deeply divided over whether to extend the credits.
Some GOP senators like Tommy Tuberville of Alabama, Josh Hawley of Missouri, and Lisa Murkowski of Alaska have signaled openness to an extension to prevent their constituents from facing ballooning costs.
But support is far more limited in the House. While Speaker Mike Johnson (R-La.) has acknowledged that the issue is under consideration, many rank-and-file Republicans are resistant. Ways and Means Chair Jason and Smith (R-Mo.) have indicated that continuing the credits would be a tough sell within his conference.
The Trump administration has also signaled opposition, framing the credits as part of a temporary COVID-era expansion pushed by Democrats, which could further complicate any GOP-led effort to preserve them.
At the same time, other Republicans, including some in swing districts and moderate states, face growing pressure. Political advisers warn that undercutting Obamacare subsidies could inflict significant political damage and lead some Republicans to privately support bipartisan negotiations to prevent a sharp premium and coverage losses.
Still, there’s a narrow window for action. A bipartisan agreement to extend the credits could theoretically hitch a ride on a larger legislative vehicle, such as an appropriations package or the NDAA. But absent a deal, the default is inaction, which could spell catastrophe for millions of Americans.
Polling shows that Democrats have the upper hand politically: Six in 10 Americans disapprove of the GOP’s megabill, most believe it will raise their health care costs, and 55 percent say they would not support someone who voted to cut Medicaid. Voters overwhelmingly see the changes as helping the wealthy while hurting working- and middle-class families.
And Democrats plan to spend the August recess reminding Americans in blue and red districts alike of what they perceive to be President Trump’s failure to fulfill his signature campaign promise to lower costs on day one of his second term.
“We’re six months into this Trump administration, and prices are rising because of reckless tariffs. Inflation is still too high, and now health care costs are going to skyrocket for the 24 million Americans who rely on the Affordable Care Act,” House Democratic Caucus Chair Pete Aguilar (D-Calif.) said. “At a time when family budgets are stretched thin, Republicans are only prioritizing the needs of billionaires. It’s not just bad policy that will make the economy worse. It’s a slap in the face to working people.”
Michael Jones is an independent Capitol Hill correspondent and contributor for COURIER. He is the author of Once Upon a Hill, a newsletter about Congressional politics.
