Illustration: Allie Carl/Axios
Senate Republicans haven't ruled out the idea of extending enhanced Affordable Care Act subsidies in a reconciliation package next year, leaving a sliver of hope for a priority of hospitals, insurers, and provider and patient groups.
Why it matters: If the subsidies are allowed to expire at the end of 2025, millions more will lose health coverage or their premiums will rise, projections show.
- That could prove a political liability for Republicans, since the subsidies have overwhelmingly benefited red states that haven't expanded Medicaid.
By the numbers: The CBO 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.
Republicans this week rejected an offer by Democrats to wrap a one-year extension of the ACA subsidies into a year-end health package.
What they're saying: But the issue could still be in play next year, Senate Republicans told Axios over the past week.
- Incoming Senate Finance Chair Mike Crapo said that the subsidies could be included in reconciliation, adding that "what I can tell you is that everything is on the table" and "I don't know that that's been singled out yet, at least not in my deliberations."
- Soon-to-be HELP Chair Bill Cassidy said it was "kind of premature" for him to discuss prospects but said "it might be on the table, but I've not talked beyond it might be on the table."
- Senior Senate Finance member Chuck Grassley also told Axios that he hadn't heard any discussions of the subsidies, saying "I think you got to figure everything's on the table" and "We'll wait until we get into negotiations deciding what" that would be.
But in the House, some GOP members were more pessimistic about wanting anything to do with ACA subsidies.
- Ways and Means Chair Jason Smith refused to answer when asked twice whether there's been talk of ACA subsidy extensions in reconciliation.
- House Budget Chair Jodey Arrington responded, "Hell no" when asked if he could envision a subsidy extension.
Still, even House Freedom Caucus members like Rep. Chip Roy see the need for health care, if not necessarily ACA subsidies, to be a part of the reconciliation discussion.
- "Oh, 100%," Roy told Axios, referencing alternate coverage proposals like "expansive health savings accounts" and "health care freedom."
- "It's not about 'Oh, are we doing ACA subsidies?' It's 'What are we doing through reconciliation to fix healthcare?'" he said.
The other side: Current Senate Finance Chair Ron Wyden 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.
- Association health plans, short-term limited duration plans and health reimbursement arrangements were all pitched as alternatives to ACA marketplaces during the first Trump administration.
