Well, the fate of the Patient Protection and Affordable Care Act’s (PPACA’s) enhanced premium tax credits, or PTCs, still hangs in the balance. And like my colleague Cate Brantley promised last Monday, I’m here to weigh in on how things played out last week in Congress with extending the subsidies, which expire at year’s end, and what to expect as 2025 draws to a close.
Despite months of debate and two critical votes in the Senate last week, Congress has failed to reach consensus on extending the subsidies, leaving millions of Americans uncertain about their health coverage for 2026.
As you may know, the enhanced PTCs were originally expanded under pandemic-era legislation. The bipartisan agreement that reopened the government in November set a deadline of last Friday for the Senate to act on the extension – a deadline that has now passed without those subsidies being extended.
Last week, two competing Senate proposals fell short. First, a Democratic plan to extend the credits for three years was narrowly defeated, 51–48. Similarly, a Republican alternative that would direct funds to health savings accounts failed by the same margin. And even if either measure had passed, the House would still have needed to approve it, highlighting the uphill battle for any resolution.
With these setbacks, prospects for continuing the enhanced subsidies appear bleak. Lawmakers on both sides admit that a bipartisan compromise is unlikely before year-end. And a recently published Government Accountability Office (GAO) report documenting PPACA-related fraud may have further weakened support for the tax credits.
Adding to the complexity, the Congressional Budget Office (CBO) recently estimated that a three-year PTC extension would insure an additional four million people by 2028, but increase the federal deficit by nearly $83 billion over the next decade – a figure that has heightened anxiety over budgetary implications among deficit hawks.
With the PTCs likely not to be extended, some states report enrollment declines of up to 33 percent. Additionally, polling suggests that as many as 25 percent of current enrollees could drop coverage if the PTCs expire. Yet, in a surprising twist, the Centers for Medicare & Medicaid Services (CMS) announced last week that overall PPACA enrollment is slightly ahead of last year, defying predictions that many would drop out.
In the meantime, states are scrambling to manage potential fallout by taking strategic actions such as bolstering reinsurance programs, offering their own premium support, and ramping up public outreach to encourage consumers to shop for affordable plans. Meanwhile, hospitals are bracing for a surge in uncompensated care and increased emergency-room visits if coverage gaps widen.
On Capitol Hill, all is not lost…yet, but the political stakes are high. Swing-district Republicans fear backlash if subsidies lapse, while Democrats face pressure to decide whether to compromise or hold firm on a full extension.
As soon as this week, the House is set to vote on a Republican healthcare package that does not include an PPACA tax credit extension, focusing instead on measures like Pharmacy Benefit Manager (PBM) transparency and small-business coverage assistance.
However, GOP leaders plan to allow votes on amendments to this package for modified PTC extensions – such as requiring minimum premiums or a one-year extension, with income caps on eligibility – but these proposals are expected to fail, and face long odds in the Senate even if they did pass the House.
Now, as the clock continues to tick down, the question remains the same as last week: Will lawmakers find a path forward, or will millions potentially lose financial support for health coverage?
For now, nearly all indications suggest that a subsidy extension will not advance, as Congress adjourns for the final time this Friday.
Anyone who has worked within the scope of hospital case/utilization management for any period of time has heard of the Centers for Medicare & Medicaid
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