{"id":2110745,"date":"2025-11-06T14:00:00","date_gmt":"2025-11-06T19:00:00","guid":{"rendered":"https:\/\/kffhealthnews.org\/?p=2110745&post_type=podcast&preview_id=2110745"},"modified":"2025-11-07T10:48:39","modified_gmt":"2025-11-07T15:48:39","slug":"what-the-health-421-affordable-care-act-enrollment-premiums-shutdown-congress-november-6-2025","status":"publish","type":"podcast","link":"https:\/\/kffhealthnews.org\/news\/podcast\/what-the-health-421-affordable-care-act-enrollment-premiums-shutdown-congress-november-6-2025\/","title":{"rendered":"What the Health? From KFF Health News: The State of the Affordable Care Act"},"content":{"rendered":"\n
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\n\t\t\tJulie Rovner is chief Washington correspondent and host of KFF Health News\u2019 weekly health policy news podcast, \u201cWhat the Health?\u201d A noted expert on health policy issues, Julie is the author of the critically praised reference book \u201cHealth Care Politics and Policy A to Z,\u201d now in its third edition.\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\t<\/div>\n<\/div>\n\n\n\n

Open enrollment for health plans under the Affordable Care Act began Nov. 1, yet it remains unclear how much the estimated 24 million Americans who purchase from the ACA marketplaces will be expected to pay in premiums starting in January. Unless Congress acts to extend tax credits added to the program in 2021, most consumers will be expected to contribute much more out-of-pocket; in some cases, double or triple what they are paying in 2025. <\/p>\n\n\n\n

The politics of this year\u2019s ACA fight are also complicated. Democrats are using the only leverage they have \u2014 a government shutdown \u2014 to try to force Republicans to negotiate over the expiring ACA tax credits. Yet many, if not most, of the people who will face much higher premiums in 2026 are from GOP-dominated states such as Texas and Florida, and belong to professions that tend to be more Republican than Democratic, such as farmers and ranchers, or small-business owners. <\/p>\n\n\n\n

In this special episode of \u201cWhat the Health?\u201d from KFF Health News and WAMU, host Julie Rovner talks to Cynthia Cox, a vice president at KFF and the director of its Program on the ACA. Cox explains what the nation\u2019s health system looked like before the passage of the health law, how it has contributed to lower health spending and better insurance coverage, and the peculiar politics of the current fight.<\/p>\n\n\n\n

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[Editor\u2019s note:<\/em><\/strong> This transcript was generated using both transcription software and a human\u2019s light touch. It has been edited for style and clarity.]<\/em> <\/p>\n\n\n\n

Julie Rovner:<\/strong> Hello from KFF Health News and WAMU Public Radio in Washington, D.C. Welcome to \u201cWhat the Health?\u201d I\u2019m Julie Rovner, chief Washington correspondent for KFF Health News. <\/p>\n\n\n\n

Usually, I\u2019m joined by some of the best and smartest health reporters in Washington, but today we have a special episode. We\u2019re taping this week on Monday, Nov. 3, at 10 a.m. As always, and especially this week, news happens fast, and things might\u2019ve changed by the time you hear this. So here we go. <\/p>\n\n\n\n

Today, we\u2019re going to explore the state of the Affordable Care Act with one of my favorite experts, KFF\u2019s Cynthia Cox, who\u2019s a vice president and director of the program on the ACA. Open enrollment for 2026 health plans began on Saturday, Nov. 1, and there is so much confusion. I thought it would be helpful to see where we\u2019ve been and, possibly, where we\u2019re going. <\/p>\n\n\n\n

Cynthia, thank you so much for joining us. <\/p>\n\n\n\n

Cynthia Cox:<\/strong> Yeah, thanks for having me, Julie. <\/p>\n\n\n\n

Rovner:<\/strong> I want to start by reminding everyone how the Affordable Care Act changed the health care system, what problems the law tried to solve, what problems were left for another day. I feel like people have either forgotten or never knew what things were like pre-the ACA. <\/p>\n\n\n\n

Cox:<\/strong> It has been quite awhile, so let\u2019s, I guess, rewind 15 years or so. <\/p>\n\n\n\n

There were a couple of big problems that the ACA was trying to address in the U.S. health care system. One was that there were a lot of people who were uninsured. And that was partly because of cost reasons and partly because of the second big problem that the ACA was trying to solve, which was that people who have preexisting conditions were often denied access to health insurance. <\/p>\n\n\n\n

And to explain that a bit more, what that looked like, was if you had a serious illness like cancer or diabetes or some other illness that might require expensive treatments, and if you had any gap in your coverage \u2014 say, you left your job and then needed to find some other health insurance after a period of time \u2014 then the insurer would often just deny your application and say they wouldn’t insure you. And if you had a less severe condition, maybe even something like acne where you needed Accutane treatment or something, then they would still give you insurance, but they could charge you more. They would charge a surcharge for covering that preexisting condition. <\/p>\n\n\n\n

And then still another issue with preexisting conditions was that insurers didn’t have to cover your treatment for a condition, too. So, you might get a health insurance coverage for certain treatments but, say, it might exclude mental health treatment or even pregnancy care or prescription drugs or other things that didn\u2019t need to … There was no minimum standard for what needed to be included in these health insurance plans that were sold to individuals. <\/p>\n\n\n\n

Usually, insurance that was sold to larger businesses or that larger companies offered was pretty comprehensive. The ACA did make some changes to those plans, too, like setting out-of-pocket limits and prohibiting lifetime caps. But most of the changes were in what was called the individual market, where people would buy their own health insurance on their own, usually when they were between jobs, or between school, or maybe a stay-at-home parent, or that sort of thing. <\/p>\n\n\n\n

Rovner:<\/strong> Or even a self-employed individual, which was …  <\/p>\n\n\n\n

Cox:<\/strong> Yes. Exactly. <\/p>\n\n\n\n

Rovner:<\/strong> … growing in the early parts of this century. <\/p>\n\n\n\n

Cox:<\/strong> Yeah. <\/p>\n\n\n\n

Rovner:<\/strong> I think people don’t remember how much of a wild West the individual market really was at that point. The Congress had regulated the employer market in 1996 with HIPAA [Health Insurance Portability and Accountability Act], which was about a lot more than confidentiality. But that\u2019s for another day. But the individual market was so crazy that you could get insurance \u2014 it wasn’t really insurance \u2014 or you could get charged more just for being a woman, right? <\/p>\n\n\n\n

Cox:<\/strong> Exactly. You could even be charged based on what your job was. People who had risky professions might\u2019ve been excluded from health insurance, too. There were very few rules or standards in this market, it was … <\/p>\n\n\n\n

One insurer might have insured you, and another insurer wouldn’t have. And there was no way to really know what was going to be available to you without having to maybe apply to multiple companies and go through a lengthy underwriting process, too. <\/p>\n\n\n\n

Rovner:<\/strong> How did the ACA change that? <\/p>\n\n\n\n

Cox:<\/strong> The ACA created a lot of standards, and the way that it did that was to say: Here are the only ways that you can vary premiums.<\/em> Rather than having rules about every single little thing that could have been covered, the ACA was basically like, OK, here are the only ways that insurers can change things.<\/em> <\/p>\n\n\n\n

The only ways that insurers can change premiums are based on how old you are, where you live, and if you smoke cigarettes or used tobacco, and then also, just how many people are signing up for the coverage. So basically, if your whole family is signing up, then obviously that\u2019s going to be more than if just you is signing up. <\/p>\n\n\n\n

And then it basically prohibits all those other things, like you can\u2019t rescind coverage based on preexisting conditions or exclude coverage based on preexisting conditions, or … It basically is saying: If you have a preexisting health condition, that is not a reason for an insurance company to charge you more or deny you coverage or carve out certain benefits.<\/em> So now the health insurance that is sold to individuals \u2014 which now we\u2019ve started calling these the ACA marketplaces or Obamacare markets or that sort of thing \u2014 so that coverage that\u2019s sold there looks a lot more like the coverage that had been available to people with large employer coverage before the ACA. <\/p>\n\n\n\n

Basically, it was trying to bring the standards for individual insurance coverage up to what already had been the standards for employer coverage. And, in doing so, it made health insurance more expensive in the individual market because when health insurers have to pay out claims for people who are sick, then that brings up their average costs, which they have to spread out, meaning higher average premiums that they\u2019re charging. <\/p>\n\n\n\n

Those premiums today are no more expensive than the premiums that employer plans have. They cover similar benefits. It costs about the same, but when you get coverage through work, your work is paying for a large part of that premium. And when you pay your premium, it\u2019s usually with some sort of tax benefit, too. So I think a lot of us who have employer coverage just don\u2019t realize how expensive employer coverage is. And the ACA … <\/p>\n\n\n\n

Rovner:<\/strong> We also don\u2019t realize how much we\u2019re getting subsidized by the government because that\u2019s … <\/p>\n\n\n\n

Cox:<\/strong> That, too. Yes. <\/p>\n\n\n\n

Rovner:<\/strong> … one of the big fights. It\u2019s like: Why are we giving these people subsidies?<\/em> It\u2019s like: You’re getting a subsidy, too, if you have employer coverage.<\/em> <\/p>\n\n\n\n

Cox:<\/strong> Yeah, exactly. Yeah, it\u2019s a tax benefit. <\/p>\n\n\n\n

And so basically, in the individual market or Obamacare markets, the premiums \u2014 the raw total gross, whatever word you want to say, how much the insurance company is charging \u2014 is about the same as in the employer market, and it covers about the same services. It\u2019s very similar coverage, and that\u2019s why it\u2019s expensive. But that\u2019s also why there are tax credits that are available to help individuals afford coverage. Because if you\u2019re low-income, there\u2019s no way you\u2019re going to be able to afford full-price health insurance. <\/p>\n\n\n\n

Rovner:<\/strong> And the tax credits have been a big boon to this market, right? Including … <\/p>\n\n\n\n

Cox:<\/strong> That\u2019s right. <\/p>\n\n\n\n

Rovner:<\/strong> … the expanded tax credits from 2021. <\/p>\n\n\n\n

Cox:<\/strong> Yeah. The ACA included premium tax credits to begin with. But the enhanced tax credits \u2014 which is what Congress is debating right now \u2014 those were passed in 2021, and those basically just boosted the amount of financial assistance that people were getting. <\/p>\n\n\n\n

When the ACA was first passed in 2010, there was a lot of talk about, well, how do we make health insurance affordable, but also how do we define what affordable is?<\/em> There was not really a standard against which to say, OK, this is what a low-income person can afford to pay. This is what a higher-income person can afford to pay.<\/em> <\/p>\n\n\n\n

And so there was a table basically in the law that said, at the time, that a low-income person would pay 2% of their income for a premium, and a higher-income person would get no financial help, but a middle-income person would pay 10% or so of their income. And it turned out that that definitely helped people afford coverage.  <\/p>\n\n\n\n

But a couple of issues that existed in the early ACA were that those higher-income or even middle-income people were priced out of health insurance if they didn\u2019t get a tax credit. And those were often small-business owners, or entrepreneurs, or self-employed people who were a pretty vocal group about how they were being harmed by higher premiums and not getting any financial help to pay for their costs. This was a group that got a lot of media attention and was really part of why we were even talking about repealing or replacing the ACA. It was that group of people who did not get any financial help but had higher premiums that were really, arguably, harmed by the ACA, especially if they had been healthy and had been able to get insurance before the ACA. That was one issue. <\/p>\n\n\n\n

And then the other issue was just that take-up was not as high as what expectations had been, and I think a lot of that was even for lower-income or people who were getting a tax credit, maybe they just weren’t getting enough financial assistance to make that coverage affordable or attractive. <\/p>\n\n\n\n

Rovner:<\/strong> And we should talk about the mandate, because that was the big fight over the ACA \u2026 the idea was if you were going to let all these sick people into the individual market, we needed to get more healthy people into the individual market. And maybe the tax credits wouldn\u2019t be enough, so we\u2019re going to require people to either pay a tax penalty or buy insurance. And that was so controversial that it got repealed. <\/p>\n\n\n\n

Cox:<\/strong> Yeah. The idea here was, well, if you\u2019re going to allow people with preexisting health conditions to come in and buy health insurance, what\u2019s to stop them from waiting until they get sick to get that coverage? And if they do that, then there was this word that suddenly everyone became a health economist back in 2010 and heard about adverse selection or death spirals. <\/p>\n\n\n\n

And so the concern was that if you wait until you\u2019re sick to get health insurance \u2014 if everyone waits until they\u2019re sick to get health insurance and only sicker people are buying health insurance \u2014 then basically that makes premiums astronomically high. No insurance company is going to want to even participate in a market like that because it could lead to what\u2019s called a death spiral \u2014 meaning the premiums just get higher and higher and higher and higher until no one can afford to purchase that coverage. <\/p>\n\n\n\n

And so the individual mandate, sorry, was one way in which people were basically compelled to purchase insurance and not wait until they were sick. Basically, there were carrots and sticks in the ACA. The sticks were the individual mandate and also this short open enrollment window. So if you didn\u2019t sign up during open enrollment and you found out you had some serious illness after open enrollment ended, you would have to wait until the next open enrollment to sign up. And then the carrot was the tax credit, basically making coverage affordable. <\/p>\n\n\n\n

So when the individual mandate penalty was reduced to $0 \u2014 effectively getting rid of the individual mandate \u2014 there was a lot of concern that that was going to lead to a death spiral or adverse selection at least. It didn\u2019t really play out that way, I think, because what really mattered was the carrots. The open enrollment window is still there as a stick, but I think people want health insurance. It just needs to be affordable enough for them to get it. And so the tax credits are really key there to making the coverage affordable and attractive for someone to buy it even if they are not sick. <\/p>\n\n\n\n

Rovner:<\/strong> And the enhanced credit just made the carrot that much bigger, right? <\/p>\n\n\n\n

Cox:<\/strong> Yeah. It basically supersized the carrot. <\/p>\n\n\n\n

That\u2019s when you see when these enhanced tax credits rolled out, people started buying this coverage a lot more. The markets doubled in size. It went from about 11 million people signed up to over 24 million people signed up just within a few years of these enhanced tax credits being available. <\/p>\n\n\n\n

Rovner:<\/strong> So there were also some things in the ACA that were supposed to help dampen, if you will, the acceleration of health care spending. The consensus is those didn’t work quite as well, but they were there, right? It\u2019s not that [the] law just ignored the cost of health care. <\/p>\n\n\n\n

Cox:<\/strong> Yeah. The law did not ignore the cost of health care. But I will say, I think the primary emphasis was on making health insurance affordable for individuals rather than making it affordable for our society. There were some measures put in place to slow the growth of health care. And actually, another thing that President [Donald] Trump did in his first term was use authority from the ACA to implement price transparency rules for hospitals to try to get at hospital prices. And there were, of course, other efforts, too, but I would say nothing that really made a huge impact on total health care spending as a nation. <\/p>\n\n\n\n

We have seen health care spending has slowed. It\u2019s not growing as quickly as it was before the ACA in general. I don\u2019t know if you can attribute all of that to the ACA, though, but we still are, as a nation, spending about 20% of our GDP [gross domestic product] on health care. Whereas other countries that are large and wealthy, like the United States, spend closer to 10, 11, 12% of their GDP, and that\u2019s regardless of whether they\u2019re a single-payer nation or not. Even countries that have multiple payers will still spend significantly less on health care than the United States does. <\/p>\n\n\n\n

Rovner:<\/strong> But the Republican talking point that this is all, that health care spending has gotten out of control because<\/em> of the ACA isn\u2019t true. <\/p>\n\n\n\n

Cox:<\/strong> Yeah, no. In fact, I think health care spending growth has slowed since the ACA. <\/p>\n\n\n\n

When you look at the individual market, which is where so much of the emphasis has been in changing how preexisting conditions are covered and that sort of thing, yes, premiums are higher today in the individual market than they were in the pre-ACA individual market. But individual market premiums today are really similar to employer premiums today, where the ACA, really, barely touched those plans. <\/p>\n\n\n\n

I think the issue is that health insurance is just really expensive in this country, and it\u2019s really expensive because we spend a lot on … we pay high prices for doctor\u2019s visits, hospital stays, prescription drugs. And the ACA did do some things to try to address those underlying reasons why health care is so expensive in the U.S., but it wasn\u2019t really the main focus. I think the main focus of the ACA was to subsidize coverage and make it affordable for individuals. But that still means that it\u2019s expensive for society. <\/p>\n\n\n\n

Rovner:<\/strong> So who are the individuals in the ACA individual market, if you will? There\u2019s \u2014 what? \u2014 24 million of them? <\/p>\n\n\n\n

Cox:<\/strong> Yeah. There\u2019s 24 million of them, and about half of them are either small-business employees, or owners, or self-employed people, and that\u2019s because a lot of us get coverage through work. <\/p>\n\n\n\n

But we work at bigger companies where that company offers a benefit as part of your total compensation package. You get your salary, and you also get your health insurance. Smaller companies often do not offer health insurance. They\u2019re not required to, especially very tiny companies like mom-and-pop shops or that sort of thing. Also, even people who are not affiliated with a small business are still usually working or in a working household. They might just be working part-time, or they might be a stay-at-home parent where their spouse works, and they just don\u2019t get health insurance for themselves. <\/p>\n\n\n\n

And so generally speaking \u2014 because you have to have an income of at least the poverty level to be getting a subsidy in this market \u2014 these are working individuals or working families. Also, a lot of farmers and ranchers rely on the ACA marketplace because, again, that\u2019s a field where they don\u2019t necessarily get health insurance through work. So that\u2019s a big part of it. <\/p>\n\n\n\n

The other thing that\u2019s pretty common is pre-retirees or early retirees. So basically, people who are not quite old enough to be on Medicare \u2014 since you have to be 65 to get on Medicare \u2014 you see a lot of 64-year-olds buying ACA marketplace coverage. <\/p>\n\n\n\n

Rovner:<\/strong> I think the thing that confuses most people, at least the most people that I talk to, is that we keep hearing that ACA premiums are going up an average of 17% next year, or 30%, or more than 100%. And all of those numbers are actually correct because they\u2019re referring to different things. So what\u2019s the difference between premiums the insurers charge and the premiums consumers have to pay? <\/p>\n\n\n\n

Cox:<\/strong> Yeah, there are too many percentages out there for a normal person to keep track of, so I will do my best to explain it. <\/p>\n\n\n\n

Basically, there\u2019s two ways to think about premiums in the individual market. There\u2019s how much the insurance company is charging for their premiums. That\u2019s the revenue that the insurance company is bringing in. But a lot of that is not paid by individuals. The federal government is paying a large share of that in the form of a tax credit. <\/p>\n\n\n\n

So then the other way that people think about premiums in this market is how much individuals are paying out of their own pockets for their premiums. And if you\u2019re just a regular person shopping on healthcare.gov<\/a>, that\u2019s what you see as your premium payment is how much you have to contribute as an individual. <\/p>\n\n\n\n

The amount that the insurance companies are charging, we have a couple of different numbers on that. We have what they requested to state regulators was an 18% increase on average. Four percentage points of that, they were saying, was this extra premium increase that they weren\u2019t otherwise going to charge. But they were saying, we think that when these enhanced tax credits expire, that healthier people are going to drop their coverage, meaning we\u2019re going to be left with a sicker group of enrollees, so we\u2019re going to have to charge even higher premiums than we otherwise would have. <\/em>Either way, even if the enhanced premium tax credits had been extended, insurers in this market still would\u2019ve been raising premiums by double digits. <\/p>\n\n\n\n

That\u2019s the steepest increase that we\u2019ve seen in many years in this market. But we\u2019re also, I think, looking at double-digit premium increases for employer plans, too. It\u2019s just an expensive year coming up. That\u2019s how much … <\/p>\n\n\n\n

And then we have newer data that just looks at silver plans. This is super wonky. But basically, a certain plan that is the benchmark against which subsidies are calculated. The insurers are actually charging 26% more on average for that plan. So I think that these requested rates might\u2019ve understated how much insurers are actually charging. And so these are really significant premium increases. But … <\/p>\n\n\n\n

Rovner:<\/strong> I would say a really important piece of this is that if the tax credits weren\u2019t changing, people wouldn\u2019t be paying these increases. Right? They would be absorbed … <\/p>\n\n\n\n

Cox:<\/strong> Exactly. <\/p>\n\n\n\n

Rovner:<\/strong> … by the tax credit. <\/p>\n\n\n\n

Cox:<\/strong> Yeah. Nine out of 10 people in this market get a tax credit right now. And if the tax credits were extended, people would pay the same next year that they do this year. Their out-of-pocket premium payment would be held relatively flat. They would not be paying these increases that insurance companies are charging. <\/p>\n\n\n\n

Looking into next year, there are people who will lose the tax credit altogether if the enhanced tax credits expire. These are the middle-income, small-business owners who we were talking about before. They will lose the tax credit. So they will get less financial help or no financial help, and then they will also have to pay this double-digit premium increase that insurers are charging. So that\u2019s this double-whammy effect for that group of people. <\/p>\n\n\n\n

But even the people who continue to get a tax credit, they\u2019ll just get a smaller tax credit next year. They\u2019re still also going to see their premium payments go up, not because of what the insurance company is charging, but because of Congress not extending the enhanced premium tax credits. So that means that they have to pay a larger share of their income. So a low-income person, instead of paying nothing each month, will have to start paying 2% to 4% of their income. A middle-income person, instead of paying maybe 6% to 8% of their income, might pay 8% to 10% of their income. <\/p>\n\n\n\n

Again, for most people, this is not a function of what the insurance company is charging. It\u2019s actually a function of what Congress sets the law to be and how much of a tax credit they get. <\/p>\n\n\n\n

Rovner:<\/strong> If the tax credits do expire, as currently scheduled, is there any way for people to offset that increase, like buying a less generous bronze plan instead of a silver plan? And what would that mean for their out-of-pocket spending on health care? It\u2019s a trade-off, right? <\/p>\n\n\n\n

Cox:<\/strong> Yeah. Our analysis shows that if people stay in the same plan, they would see a premium increase of 114% on average. But for many people, it could be an option to switch to a lower level of coverage. So maybe instead of buying a silver plan, they buy a bronze plan. <\/p>\n\n\n\n

But the issue there is, a lot of the people who are buying ACA marketplace coverage right now are so low-income that they\u2019re getting really generous financial help for their deductibles, too. It\u2019s not just their premiums. So instead of a silver premium having a deductible of a few thousand dollars for that person, their deductible might be less than a hundred dollars now. And so if they were to switch from a silver plan to a bronze plan, they might still be able to keep a zero premium payment, or near-zero premium payment, but their deductible would be $7,000 more than it is today. Either way, they\u2019re going to see their costs go up. It\u2019s just, do they see them go up when they go to the doctor, or have an emergency, or have a hospitalization, or fill a prescription drug? Or do they see their monthly costs go up for each month that they\u2019re paying their premium? <\/p>\n\n\n\n

If you\u2019re young and healthy, it might make sense to take the risk and get the bronze plan. But if you\u2019re pretty sure you\u2019re going to use some health care next year, then it makes sense to just pay the higher premium so that you can keep that low deductible. <\/p>\n\n\n\n

Rovner:<\/strong> Yeah. One of the main Republican talking points is all these people who have insurance but don\u2019t file claims every year, which they say is evidence of widespread fraud. But isn\u2019t it also possible that some of those people don\u2019t use their insurance because they literally can\u2019t afford these four- and five-figure deductibles? <\/p>\n\n\n\n

Cox:<\/strong> Yeah. It\u2019s also … There\u2019s a lot of reasons why someone might not use their health insurance. We certainly know whether you\u2019re getting your coverage through work or through the ACA marketplaces. If you have a high deductible, then that can be a significant cost barrier. Also, lower-income people face other non-cost-related access barriers, like getting time off of work, or just the ability to find an appointment. <\/p>\n\n\n\n

But also the market has gotten younger. And with enhanced premium tax credits attracting more people to buy coverage, this was part of the whole idea was that you get younger, healthier people to sign up for coverage and not wait until they\u2019re sick. And so that also can make it look like there\u2019s less utilization of care. But if you’re just young and healthy, then you might not be going to the doctor either way. <\/p>\n\n\n\n

And also just … <\/p>\n\n\n\n

Rovner:<\/strong> It\u2019s the opposite of the death spiral, right? <\/p>\n\n\n\n

Cox:<\/strong> Right. A health spiral is what some people have called it. <\/p>\n\n\n\n

But I think there\u2019s also just some issues with the data source that was used to do that. I won\u2019t go into all those details, but I think … there\u2019s something there. There is fraud. There\u2019s no question that there\u2019s fraud in this market. And it\u2019s being committed mostly by agents and brokers who are signing people up either without their knowledge, or switching their plan, or switching the name of the broker so they can get the commission. But I think the scale of the fraud has been exaggerated. <\/p>\n\n\n\n

Rovner:<\/strong> Something else I think has gotten pretty lost in the fight over extending these additional tax credits is that it\u2019s not the only change coming to the Affordable Care Act for 2026. Republicans made some major alterations to the law in their big budget bill that they passed last summer. Let\u2019s start with the changes to how much people might have to repay if they estimate their income incorrectly. What\u2019s that change? <\/p>\n\n\n\n

Cox:<\/strong> I think this is probably one of the biggest changes aside from the expiration of the enhanced premium tax credit, and it hasn\u2019t gotten a lot of attention. So I\u2019m worried that people who are buying their own coverage might not know about this. <\/p>\n\n\n\n

Congress has basically repealed any limits on how much you would have to repay when you file your taxes the following year after you enroll in ACA marketplace coverage. The idea is that when you sign up for ACA coverage, you have to project what you think your income will be by the end of the next calendar year. That can be really hard for someone who, say, gets their income from driving Uber or working shifts at a restaurant, or so on and so forth. Or even a small-business owner might have a hard time projecting exactly how much their income will be next year. And so, if you guess wrong \u2014 in other words, if you say, now I think I’m going to make $50,000 next year,<\/em> but you end up making $60,000 next year \u2014 then you might have to repay a significant amount of the tax credit.  <\/p>\n\n\n\n

The other simultaneous thing is that with the enhanced premium tax credits going away next year \u2014 if that actually does come to be \u2014 then this subsidy cliff will come back, meaning that if you make just a dollar too much, meaning just over 400% of the poverty level, then you\u2019ll have to repay the entire tax credit, which could be thousands, if not tens of thousands, of dollars. And so people who are right around that cutoff will need to be really careful about if they have control over their income. For some people, it might make sense to make sure that your income is below four times the poverty level. Or you can also adjust your tax credit midyear or decide to wait and get the tax credit at the time you file your taxes instead of getting it up front. <\/p>\n\n\n\n

Rovner:<\/strong> Yeah, I think this is a big deal. And also there\u2019s going to be less help available for people to actually sign up for coverage, even though there\u2019s all these big changes happening. <\/p>\n\n\n\n

Cox:<\/strong> Yeah. When the ACA was first passed, there was this idea that it was going to be like going online and booking your own hotel, or airplane, or whatever, and that\u2019s just not how it has panned out. Most people need help signing up for health insurance. It still is a complicated process. And so they turned to agents, brokers, and what are called navigators, who are nonprofit organizations that have helped people buy insurance. But the Trump administration has cut funding for the navigator program really significantly, and so there\u2019s going to be fewer of those folks to help. <\/p>\n\n\n\n

Also, I think this is just going to be probably one of the busiest and most chaotic ACA open enrollment periods ever,<\/em> probably, and so many … <\/p>\n\n\n\n

Rovner:<\/strong> 2013 wasn\u2019t great but … <\/p>\n\n\n\n

Cox:<\/strong> Yeah. But there weren\u2019t so many buying it back then. <\/p>\n\n\n\n

Rovner:<\/strong> … where the website didn\u2019t work. <\/p>\n\n\n\n

Cox:<\/strong> Yeah, yeah. <\/p>\n\n\n\n

I remember that well, but also, there were not that many people shopping. Now, there\u2019s three times as many people shopping for coverage. <\/p>\n\n\n\n

Rovner:<\/strong> True. <\/p>\n\n\n\n

Cox:<\/strong> I don\u2019t know if there are more agents or brokers than there were back then, but I suspect not. But there\u2019s just going to be busy people. And so if you need to make an appointment with an agent or broker, then go ahead and do that as soon as you can. <\/p>\n\n\n\n

Rovner:<\/strong> Yeah. This is the trade-off here. On the one hand, people want to wait and see if Congress maybe comes to some deal on these expanded subsidies. On the other hand, it\u2019s going to be really hard to sign up at the last minute. <\/p>\n\n\n\n

Cox:<\/strong> Yeah, yeah. So if it were me \u2014 and I obviously would feel more comfortable signing up on my own without the help of someone \u2014 but I would personally prefer to wait and see what happens. I wouldn\u2019t wait too long, but I might wait till Thanksgiving or early December and wait to make a decision about my plan until then. But you can\u2019t advise everyone to do that because if you need an agent or broker to help you, maybe get that appointment as soon as you can. But maybe also just keep an eye out on things and decide before Dec. 15 if you want to change your plan. <\/p>\n\n\n\n

Rovner:<\/strong> So it\u2019s not just the expanded tax credits. There\u2019s also [a] new restriction on who\u2019s eligible. There are a lot of people who are immigrants \u2014 who were here legally \u2014 who have been eligible for tax credits who no longer will be, right? <\/p>\n\n\n\n

Cox:<\/strong> Yeah. There has been a lot of talk about undocumented immigrants getting this coverage. And just to be clear, the ACA marketplaces are not where undocumented people come to get health insurance. You can\u2019t even buy this coverage without a subsidy if you\u2019re undocumented. <\/p>\n\n\n\n

Now, there had been an exception for DACA [Deferred Action for Childhood Arrivals] recipients. That is no longer going to be an option for folks. And then also even some folks who are here legally but just have not been in the country for long enough to qualify for Medicaid. So you have to be in the country for five years before you can qualify for Medicaid. And it had been that if you were, say, here for two years and still waiting to get Medicaid eligibility, you could get subsidized coverage on the ACA marketplace. And so some of those folks will no longer be able to this year, and then all of those folks will no longer be able to in the coming year. <\/p>\n\n\n\n

Rovner:<\/strong> I know the Trump administration tried to make even more changes in its annual regulation governing the marketplace, although some of those have been blocked by the courts. What are some of those changes that aren\u2019t happening this year but that people may have heard about and that may, depending on what the courts do, come into play next year? <\/p>\n\n\n\n

Cox:<\/strong> I think one of the most important ones was this idea that they were going to change how auto re-enrollment works. So a lot of people in the ACA marketplaces get a zero premium plan. And like all other health insurances out there, whether it\u2019s your homeowner\u2019s insurance or your car insurance, you just get automatically re-enrolled from one year to the next. And that\u2019s true for these ACA marketplaces, too. <\/p>\n\n\n\n

So the Trump administration had a rule that said: Well, if you were going to be auto-re-enrolled into a zero-premium plan, we want to make sure that you still want that plan. Because if you\u2019re not paying anything each month, you might be just getting automatically re-enrolled without your knowledge.<\/em> And so the idea was that you would get charged $5 a month until you actively re-enroll. That was one of a few things that was … <\/p>\n\n\n\n

There was a stay in a court decision basically saying: We need to hear more about this before the court could make a final decision.<\/em> But long story short, that\u2019s not going into effect this year. But there will be other changes to auto re-enrollment in the coming years, basically due to the summer reconciliation package where auto re-enrollment would effectively end. And so that\u2019s an even bigger deal, but that\u2019s not going into effect yet. That will be in the coming year. <\/p>\n\n\n\n

Rovner:<\/strong> Yes. So more people will have to actually go in and do something with their policy, but there are fewer people to help them. Do I have that right? <\/p>\n\n\n\n

Cox:<\/strong> That\u2019s right. Yeah. So there\u2019s going to be a lot of activity this year. This year and in coming years. Yeah. <\/p>\n\n\n\n

Rovner:<\/strong> So what\u2019s the bottom line here for people who now have Affordable Care Act coverage or who plan or hope to have it for next year? <\/p>\n\n\n\n

Cox:<\/strong> I think, first of all, watch this closely and don\u2019t make any decision about dropping your coverage or even dropping down to a lower level of coverage until probably early December is probably the right time to really make a final decision on this. You can still start making all of your plans and getting all your paperwork together and talk to an agent or broker, but just keep watching this until there\u2019s some sort of clear resolution about what\u2019s going to happen in Congress. Because if the enhanced premium tax credits do get extended, you\u2019re probably better off keeping the same level of coverage that you have now. Or for newer people, they\u2019re probably better off in a silver plan than a bronze plan in many cases. So you don\u2019t want to make a significant change to your coverage just yet until you know what\u2019s going to happen next year. <\/p>\n\n\n\n

But it\u2019s a difficult situation for people to be in. They have to, at a certain point, just make a judgment call. And I think that can lead to people picking a plan that\u2019s not necessarily the best one for them, or even going without insurance because they just don\u2019t feel like they can afford it anymore. <\/p>\n\n\n\n

Rovner:<\/strong> This is a conundrum. It\u2019s obviously a conundrum for the Democrats because they\u2019re keeping the government closed \u2014 which they normally don\u2019t want to do \u2014 demanding that these tax credits be extended. Ironically, a lot of the people who will be helped if the tax credits do get extended are Republicans in Republican states. They\u2019re small-business people. There are people in a lot of these very red states where we saw enrollment skyrocket. Why don\u2019t the Republicans want to do that? It\u2019s their voters who would be helped. <\/p>\n\n\n\n

Cox:<\/strong> Yeah. That\u2019s right. <\/p>\n\n\n\n

I think from the Republican perspective, this would be new government spending, because if Congress does nothing, these enhanced premium tax credits expire. So from the Republicans\u2019 perspective, it would cost $35 billion a year in new government spending to extend these enhanced premium tax credits. That\u2019s a lot of money, and that\u2019s coming at a time when Republicans have already shown willingness earlier in the year to make significant cuts to existing health programs like Medicaid work requirements. <\/p>\n\n\n\n

I think it is a complicated issue for Republicans and that I think many of them would just rather these enhanced premium tax credits expire. But I think you\u2019re seeing some Republicans, especially in parts of the country where premium increases would be very steep, or where maybe they\u2019re in a swing district where they\u2019re looking at this and saying, oh, actually most of the growth in the ACA marketplaces has been in Southern red states.<\/em> Most of the people benefiting from these enhanced tax credits live in a state that was won by President Trump or in a congressional district that was won by a Republican. So it\u2019s a complicated issue for Republicans. <\/p>\n\n\n\n

Rovner:<\/strong> Well, we will keep track of what\u2019s happening. Cynthia Cox, thank you so much. <\/p>\n\n\n\n

Cox:<\/strong> Thank you. <\/p>\n\n\n\n

Rovner:<\/strong> Thanks this week to our fill-in editor, Stephanie Stapleton, and our fill-in producer-engineer, Taylor Cook. A reminder: \u201cWhat the Health?\u201d is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts, as well as, of course, at kffhealthnews.org<\/a>. As always, you can email us your comments or questions. We\u2019re at whatthehealth@kff.org, or you can find me on X @jrovner<\/a> or on Bluesky @julierovner<\/a>. Cynthia, are you hanging on social media these days? <\/p>\n\n\n\n

Cox:<\/strong> Yes. @cynthiaccox on both X<\/a> and Bluesky<\/a>. <\/p>\n\n\n\n

Rovner:<\/strong> We will be back in your feed next week. Until then, be healthy. <\/p>\n\n\t\t<\/div>\n\t<\/div>\n<\/section>\n\n\n\n

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Click here to find all our podcasts.<\/u><\/a><\/em><\/p>\n\n\n\n

And subscribe to “What the Health? From KFF Health News” on Apple Podcasts<\/u><\/a>, Spotify<\/u><\/a>, the NPR app<\/u><\/a>, YouTube<\/a>, Pocket Casts<\/u><\/a>, or wherever you listen to podcasts.<\/em><\/p>\n\n\n\n

<\/p>\n","protected":false},"excerpt":{"rendered":"

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