Potential Alternatives to Address Health Care Affordability

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The Senate is set to vote in December on some form of an extension of the enhanced premium tax credits (PTCs). Originally enacted in the American Rescue Plan Act in 2021 and subsequently extended in the Inflation Reduction Act (IRA) in 2022, the enhanced PTCs increase subsidy amounts for individuals eligible for assistance with household incomes below 400 percent of the federal poverty level (FPL) and made people with income over 400 percent of the FPL newly eligible for premium assistance, if all other eligibility criteria are met. However, with the looming expiration of the enhanced credits and an 114 percent average out-of-pocket premium increase for enrollees, the question of how to ensure affordability in the ACA Marketplaces has taken center stage in Washington.

There are several legislative proposals to extend the PTC enhancements. For example, the Bipartisan Premium Tax Credit Extension Act () would extend for one year—through December 31, 2026—the existing enhanced PTC framework. Led by Rep. Jenn Kiggans (R-VA) and Rep. Tom Suozzi (D-NY), this bill has garnered support from 14 Republicans and 14 Democrats. Earlier in November, in the midst of the shutdown, another group of bipartisan lawmakers a “statement of principles” outlining a policy to extend the enhanced PTCs for two years but impose a phased-down income cap (between $200,000 and $400,000) and implement guardrails to “prevent improper payments.” Additionally, House Minority Leader Hakeem Jeffries (D-NY) offered an during the House Rules Committee consideration of before its vote on November 12 to extend the enhanced PTCs for three years—through December 31, 2028. Leader Jeffries and House Democratic leadership subsequently filed a , which requires 218 signatures to force a vote on the House floor on legislation mirroring the amendment and may appeal to (or at least put pressure on) moderate Republicans like those who have cosponsored H.R. 5145. However, 30 legislative days must pass after a bill is introduced before a discharge petition can be filed, so the timing for leveraging such a procedural mechanism may not pan out. Finally, some Democrats have supported a permanent extension of the enhanced PTCs, as proposed in legislation like the Health Care Affordability Act of 2025 (/) and the Protecting Health Care and Lowering Costs Act of 2025 (/).

Some Republicans in Washington are using the focus on affordability to advance their own policy agendas. On November 8, President Trump on social media his proposal to Senate Republicans: “I am recommending to Senate Republicans that the Hundreds of Billions of Dollars currently being sent to money sucking Insurance Companies in order to save the bad Healthcare provided by ObamaCare, BE SENT DIRECTLY TO THE PEOPLE SO THAT THEY CAN PURCHASE THEIR OWN, MUCH BETTER, HEALTHCARE, and have money left over.” The next day, Committee on Health, Education, Labor and Pensions (HELP) Chairman Bill Cassidy (R-LA) on the Senate floor, agreeing with the President’s recommendation and detailing his policy proposal for “Pre-Funded Flexible Spending Accounts.” Sen. Cassidy and other Republicans have also previously supported expanding the role of health savings accounts (HSAs). Such proposals have been criticized, including by right-leaning , for triggering the exit of younger, healthier individuals from the Marketplaces and leaving those that remain worse off, and even a potential collapse of the market. Among others, these proposals may be a focus of the November 19 Senate Finance Committee on the increasing cost of health care. While there are not yet specific legislative proposals to operationalize their policy ideas, Senate Republicans may offer these ideas as an alternative to the forthcoming December vote on enhanced PTCs.

On the House side, Republican members of the House Ways and Means (W&M) Committee are reportedly considering modifications to an earlier introduced bill—the Affordable Care and Comprehensive Economic Support through Savings (ACCESS) Act ()—in response to the President’s directive. This legislation would appropriate funding for cost-sharing reductions (CSRs) and give CSR-eligible Marketplace enrollees the option to receive that funding in an HSA if they enroll in a high-deductible health plan. Appropriating CSRs would end the practice of “silver loading” and would lower gross silver premiums, on average, relative to bronze and gold plan premiums. But in turn, this will lower PTCs and reduce the overall “buying power” of subsidized enrollees—a policy change that is likely to shrink enrollment in the Marketplace.

This group includes Rep. Don Bacon (R-NE), Rep. Tom Suozzi (D-NY), Rep. Jeff Hurd (R-CO), and Rep. Josh Gottheimer (D-NJ).

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