Health Care Affordability is Worth Fighting For

Political analysts have argued that inflation and concerns about the economy were driving factors in the 2024 presidential election. As costs for groceries continued to rise and household finances were squeezed, the overall metrics of a healthy economy were obscured or discounted for voters. At a campaign-styled rally in Pennsylvania on December 9, 2025, President Donald Trump vowed to “make America affordable again.” A recent KFF poll showed that over 60% of Americans are worried about affording the cost of health care, and 41% reported having medical debts.

The United States recently experienced the longest federal government shutdown in its history. The sticking point, which ultimately didn’t stick, was affordability of health care for low- and middle-income Americans. At center stage of the contentious debate was the enhanced Affordable Care Act (ACA) Marketplace subsidies, also known as the premium tax credits. The premium tax credits were proposed in 2021 under the American Rescue Plan Act (ARPA) and extended under the Inflation Reduction Act (IRA) in 2022. The premium tax credits limited the share of income paid for health insurance premiums from 0%– 8.5% for all households. Otherwise, only households making between 100% and 400% of the Federal Poverty Level (FPL) would qualify for tax subsidies. The One Big Beautiful Bill Act (HR1) allowed the premium tax credits to expire at the end of 2025. 

In 2025, over 24 million Americans enrolled in health insurance during the open enrollment period. The most growth occurred in marketplaces in states that had not expanded Medicaid, led by Texas with 255% growth. The temporary nature of the enhanced premium tax credits means that over 20 million Americans will see premium costs more than double as they apply for 2026 coverage. Democrats and Republicans have wrapped up the year without passing a bill to address this issue, ensuring that nothing will happen before premiums increase in January 2026. If individuals fail to pay premiums, they lose coverage and are locked out of the ACA Marketplace until January 2027, unless they experience a Qualifying Life Event (which, in most states, doesn’t even include pregnancy).

Affordability is a first-order issue for health insurance coverage. There is good evidence that lower-income Americans are price-sensitive. Economists have estimated that a 1% increase in ACA health insurance premiums can lead to a 1.7% reduction in enrollment.¹ ACA insurers are raising premiums by an average of 26% in 2026. Without the premium tax credits, currently subsidized families will see their premiums more than double, rising 114% on average. Losing health insurance exposes people to the harm of being uninsured and positions out-of-pocket health care costs against necessities such as housing, groceries, and transportation.

Enrollees making over 400% FPL will see the largest increase in their premiums in 2026. At face value, a family or individual at 400% of FPL might seem to be quite well-off making four times the poverty level, but experts agree that being above 100% FPL does not equate to being out of poverty. Notably, the FPL is not adjusted for the cost of living and it falls short of measuring the success of anti-poverty policy efforts. The FPL was developed in the early 1960s, and benchmarked as three times the second lowest-cost Economy Food Plan, which was set as the minimally nutritionally adequate diet.

Recently a wealth manager argued for $140,000 as the new FPL, positing it was better matched to the actual cost of a modest standard of living. This would be a radical change in policy, but it isn’t unfair to argue that a family of four with two adults and two children making 401% FPL ($128,921/year in 2025) will need to be budget conscious. Using the Economic Policy Institute Family Budget Calculator, just one of several calculators that rely on government data sources, in order to maintain a modest, yet adequate, standard of living (e.g., 40^th percentile of rent and low-cost food budget), a family living in Washington, DC, would need $138,333 a year to cover food, transportation, child care, taxes, and housing, not including debt and savings and excluding health care. Without enhanced premium subsidies, it is estimated that they would need to pay $21,538 a year in health insurance premiums for a silver plan with an average deductible of $5,304. If the family meets the deductible, they are over the annual budget by $36,254, not including any post-deductible cost-sharing in the health plan at the point of using care.

In other places in the country, such as Boise, Idaho, a family of two adults and two children are estimated to need $6,901 monthly or $98,387 annually to meet the modest-yet-adequate standard of living that excludes the cost of health care. Making $128,921 a year (401% of FPL in 2025) would give the family $30,534 annually to spend towards a silver plan estimated at annual premiums of $23,652 with a deductible of $6,000 without ACA enhanced premium subsidies. Should a person in the family require health care beyond the deductible, they too would be making hard choices.

Health care affordability is personal to many of us. Heidi Allen’s sister, Rachel, died uninsured at age 44, weeks after being diagnosed with stage-four cancer. As a single mom with three kids living at home and working as a nurse at a long-term care facility, her employer-offered insurance didn’t feel affordable and neither did the ACA Marketplace. She wasn’t eligible for Medicaid. When she passed out at work, workers’ compensation paid for her to seek health care for her subsequent concussion. None of her providers investigated why she passed out in the first place; she had attributed it to the frantic pace of work. Approximately eight months later, when Rachel was diagnosed with cancer in an emergency department, there were no treatment options. Affordability isn’t a hoax by Democrats, it is a painful reality for many American families. Rachel Allen was a Republican.

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