One of the biggest health agenda items next year will be whether to allow enhanced subsidies to expire for health coverage bought through Affordable Care Act marketplaces.

• And some well-placed Senate Republicans aren't ruling out including them in a legislative package.

Why it matters: If the subsidies are allowed to expire at the end of 2025 as scheduled, projections show millions of Americans will lose health coverage or their premiums will rise.

• Republicans could pay a political price too, since the subsidies have overwhelmingly benefited residents in red states that haven't expanded Medicaid.

Republican negotiators this week rejected an offer by Democrats to wrap a one-year extension of the ACA subsidies into a year-end health package.

• But GOP senators over the past week acknowledged the issue could resurface next year.
• The enhanced subsidies originated in the 2021 stimulus law and were renewed twice, with the latest extension due to expire at the end of next year.
• They've lowered consumers' premiums and driven more ACA enrollment — but at a hefty cost to the government. Some Republicans characterize them as taxpayer-funded handouts to health insurance companies.

What they're saying: Incoming Senate Finance Committee Chairman Mike Crapo (R-Idaho) said the subsidies could be included in the expedited budget reconciliation process planned for early next year.

• "What I can tell you is that everything is on the table," he said. "I don't know that that's been singled out yet, at least not in my deliberations."
• Soon-to-be Senate health committee Chairman Bill Cassidy (R-La.) said it was "kind of premature" for him to discuss prospects but said, "It might be on the table."
• Senior Senate Finance Committee member Chuck Grassley (R-Iowa) said he hadn't heard any discussions of the subsidies, saying, "I think you got to figure everything's on the table."

But in the House, GOP members are much more reluctant to consider the possibility.

• Ways and Means Committee Chairman Jason Smith (R-Mo.) refused to answer when asked twice whether there's been talk of ACA subsidy extensions in reconciliation.
• House Budget Committee Chairman Jodey Arrington (R-Texas) responded, "Hell no" when asked if he could envision subsidy extensions.

Still, even House Freedom Caucus members like Rep. Chip Roy (R-Texas) see the need for health care, if not necessarily ACA subsidies, to be a part of the reconciliation discussion.

By the numbers: Congressional scorekeepers last week estimated the effects of not extending the subsidies.

• Without an extension through 2026, the number of people without insurance would rise by 2.2 million that year. The number would increase to 3.8 million on average each year, from 2026 to 2034, if there's no permanent extension.
• Premiums are estimated to rise, from a 4.3% increase in 2026 to 7.7% in 2027 and 7.9% on average from 2026 to 2034.

The other side: Current Senate Finance Chairman Ron Wyden (D-Ore.) told Axios that Republicans should find alternative coverage options if they let the subsidies expire.

• "If they don't want to find a way to provide targeted relief to help working people pay the bills, and not get sicker when they have illnesses, they have to tell us what they want to do," Wyden said.

The bottom line: That could mean a return of some of the health care plans conservatives have touted that don't provide coverage as comprehensive as ACA plans.

Hospitals, insurers and other powerful health industry groups, as well as patient advocates, are pushing for the renewal of the ACA subsidies — meaning next year's deliberations will draw strenuous lobbying.

Why it matters: A lot of these players rely on the subsidies, which were most recently extended under the Inflation Reduction Act, and intend to put up a fight to keep them.

Driving the news: One prominent coalition, Keep Americans Covered, includes traditional adversaries like AARP, the Federation of American Hospitals, the American Medical Association and the health insurer group AHIP.

• It's cited Treasury data showing 1.6 million children rely on ACA marketplace coverage, with Florida and Texas leading the states in child enrollment.
• Failure to extend the subsidies will drive up health care premiums in marketplaces, the group says, "forcing difficult decisions for families who rely on them and leaving children at risk of losing access to essential health care services."

The other side: Many Republicans cite Congressional Budget Office estimates that permanently extending the enhanced subsidies would increase the deficit by more than $325 billion over a decade, plus billions more in interest outlays.

• Some also argue extending the subsidies amounts to papering over the poor quality of the marketplace plans themselves, and that the marketplaces are riddled with fraud — including brokers who do unauthorized enrollments or switch people among plans.

The bottom line: The debate likely will boil down to whether enough Republicans are willing to sunset a benefit that's helped many working-class Americans who'd otherwise be priced out of insurance coverage.