A Massive Health Care Shock Is Coming

TWENTY-FIVE MILLION AMERICANS are about to pay more for their health care—in some cases, a lot more. And while Donald Trump and the Republicans could stop it from happening, so far they’ve shown no willingness to do so.

The Americans at risk are non-elderly people who buy private insurance on their own, mostly through the Affordable Care Act’s online marketplaces. They are contractors and baristas, farmers and caregivers, part-time students and early retirees. They’re all over the country, some making good money and some barely getting by.

For several years, they’ve benefited from a Biden-era program that made the Affordable Care Act’s financial assistance more generous, so that coverage became cheaper by hundreds and sometimes thousands of dollars a year. During that time period, enrollment through the federal website HealthCare.gov and its state-run counterparts (like Covered California) surged to a record high. The number of Americans without insurance fell to a record low.

But now that process could run in reverse, because the program is set to expire on December 31.

Should that happen, more than 4 million people would become newly uninsured, the Congressional Budget Office predicts. Millions more would face a choice: dig deeper into their pockets to pay premiums or buy less generous policies, the kind that would leave them exposed to bigger out-of-pocket medical bills. In other words, they’d pay more up front when they pay their monthly premiums, or they’d pay more later on if they need medical care. Either way, they’d be paying more.

“This would be a huge premium shock for many people, and would mostly dwarf any gains they’re getting from tax cuts in the Republican plan that just passed,” Larry Levitt of the health research organization KFF told me this week.

That reality has started to dawn on Republican lawmakers, some of whom

have called for action. President Trump’s own pollster has warned that insurance sticker shock could be a significant political liability, given that Trump and the Republicans have made lowering the cost of living such a high priority—and that they already face a voter backlash for cutting almost $1 trillion out of Medicaid, as part of legislation that CBO thinks will leave nearly 10 million newly uninsured.

But extending the Biden-era Affordable Care Act assistance would not be free. On the contrary, it would require somewhere in the neighborhood of $30 to $40 billion a year of additional federal expenditures.

And while Republicans don’t flinch at much bigger figures when they are attached to their favorite tax cuts (in fact, they’ve come up with novel budgeting gimmicks to simply eliminate the costs on paper), few feel enthusiastic about putting that money into government health care programs—especially when, as in this case, the program is “Obamacare.”

Many still want to dismantle the program, and reason—correctly—that allowing this temporary program to lapse would move them closer to that goal.

The incentive is there. Calculations have shown the impact would be biggest in red states, partly because those states are less likely to have expanded Medicaid, leaving Obamacare marketplaces as the only alternative for people with incomes just above the poverty line. And many of the people affected are precisely the sorts that have become the GOP’s base.

“It’s that small businessperson, that independent contractor—somebody who is making a decent income but doesn’t get coverage at work, your real estate agent, your plumber, gig worker,” Wright said. “Those are constituencies that tend to be Republican, and they’re not going to just bear it and say nothing.”

Not all Republican lawmakers are as adamantly opposed as Harris is to fixing the problem. “I’m not saying where I am on that issue, but it’s definitely part of the conversation,” House Ways and Means Chairman Jason Smith (R-Mo.) said to NBC News. “There’s some interest to do something. There’s some interest to do nothing. So it’s threading that needle.”

A number of other conservative Republicans have said they’re willing to discuss the idea. Perhaps most significantly, House Speaker Mike Johnson told NBC the issue is “on the radar.”

But inertia is still on the side of doing nothing. That’s probably not going to change unless Trump and GOP leaders push to make it happen. So far, they’ve given no indication they want to do so. And they’re running out of time to change their minds.