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Four million people may lose health insurance on January 1st.
Not because of a pandemic or Medicaid unwinding. Because Congress can't agree to extend the enhanced ACA subsidies that expire December 31st—and open enrollment is already underway.
If subsidies expire, here's what happens:
People making over $60,000 (400% FPL) lose all subsidy help
Everyone else sees premiums roughly double—from $888/year to $1,904/year
The Urban Institute projects 7.3 million will lose marketplace coverage
But here's where it gets a bit complicated: enhanced subsidies may have masked premium inflation without fixing it. Since 2021, insurers raised premiums knowing the government would cover most increases for subsidized enrollees. Competition didn't drive prices down, everyone raised prices together.
From 2014-2024, the seven largest insurers made over $500 billion in profit. That's more than enough to fund enhanced subsidies for the next decade.
In the full report, I break down:
How ACA subsidy formulas actually work (with real examples)
Why the "benchmark premium" matters and what metal tiers mean
What changed in 2021 with enhanced subsidies
The two scenarios for 2026 and impact on patients
Why this debate isn't as simple as "help people or don't"
Where premiums and deductibles have actually gone since 2014
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