The final enrollment deadline to sign up for 2026 health insurance through the Affordable Care Act is on Thursday.
It comes as uncertainty over federal subsidies that expired Jan. 1 – raising premiums for many enrollees – has millions of Americans watching Washington closely.
Advocates warn that without an extension, more than 1 million Floridians could be priced out of marketplace plans.
Julie Rovner, KFF Health News chief Washington correspondent and a longtime health care reporter, joined WUSF’s “Florida Matters Live & Local” on Monday to help explain what Congress is debating and how people are dealing with the uncertainty.
Here is a transcript of her conversation with host Matthew Peddie. It was lightly edited for clarity and length.
FMLL: On average, people saw monthly costs rise 100% or more. Just walk us through those numbers. What were you seeing in your reporting?
ROVNER: People are seeing sticker shock. Basically, it's not so much that the premiums are going up – although premiums are going up around 20% – but with the changes in the subsidies, it means the share of the premium being paid by the federal government compared to the share that's expected to be paid by the consumer is dramatically changing, and that's why people are seeing their premiums sometimes double or triple or quadruple.
It's especially dramatic for people who are older, who are allowed to be charged higher premiums by insurers because they use more health care. And people who were toward the bottom of the income scale, who were going from getting basically subsidized for the entire cost of their health insurance plan, some of them are now having to pay, even if it's only $50 or $100. If you're just barely over poverty, that can be completely out of reach for you on a monthly basis.
And those are two big chunks of the Florida population, right? Because we do have a lot of folks retiring here. There's a lot of people working low-wage jobs in Florida. So presumably, they're affected quite significantly by these subsidies expiring.
That's right. And I should point out it's not really seniors. People who are on Medicare are not affected by this, but it's those people who are what we call the near-elderly, the early retirees, the people who are between age 55 and 64 who are being hit the hardest by these premium increases.
Walk us back to the end of last year because we had time running out on extending the subsidies. It seems now there is a bit of hope for an extension. What is happening?
That's right. The Democrats had been complaining about this, really, all year. It wasn't until the fall that it captured the public’s attention, and obviously it was the Democrats who were trying to make a stand on this issue that caused the shutdown of the government for 43 days in October and into November. In exchange for reopening the government, the Democrats were promised a vote in the Senate, which they got, and except they did not get the 60 votes needed to extend the subsidies.
But in the House, kind of surprisingly, a number of Republicans joined in a Democrat effort to force a vote on this. That happened in late December, so the vote didn't happen until last week, but 17 Republicans ended up voting with all of the chamber’s Democrats to basically reinstate these subsidies because they expired on Jan. 1.
Now it's gone back to the Senate, where they must decide: Do they want to have the vote on this that failed in December? Do they want to try to come up with a compromise, and there's a group working on that? So, we're sort of in this middle place where everybody is scurrying around trying to figure out what happens next.
Did lawmakers go back to their constituencies and get a barrage of people saying, “Hey, look, I'm terrified of my subsidies expiring,” or did they just have a change of heart over the holidays? What do you think happened?
I think it's combination. Lawmakers went home. And there are a lot of people who buy their insurance coverage through the Affordable Care Act. It's about 24 million people. The Republicans keep saying, “Oh, it's only 7% of the population,” but that's still many millions of people. Also, we're seeing pollsters who are talking to voters saying, “This isn't right.” So, I think it's combination of hearing from their constituents and hearing from their pollsters about what it means to allow these extra subsidies to expire.
As you pointed out, discussions are happening among senators to potentially pass a version of a bill. It's kind of complicated, though. What exactly did the House decide?
The House decided just to do the straight three-year extension. These were additional subsidies.
We should point out that there were always subsidies in the Affordable Care Act. That was sort of the deal in 2010, when the law passed. If you're on Medicare or Medicaid, the government pays a big chunk. If you get insurance from your employer, not only does your employer subsidize you, but the federal government subsidizes your employer to subsidize you and subsidizes you because you don't have to pay taxes on the value of that health insurance. Employer health insurance, you know, can cost $27,000 a year for a family. So, everybody was getting subsidized, except the people who bought their own insurance, people who were self-employed, people who didn't have job insurance. The subsidies originally in the Affordable Care Act were to help people afford their health insurance.
In 2021 during COVID [with people out of work and unable to get employee insurance], the Democrats in Congress with Democrat President Joe Biden, made those subsidies. And that turned out to be a key for a lot of people to be able to get health coverage. Enrollment doubled from about 12 million to 24 million people. The subsidies were temporary, not because the Democrats wanted them to be temporary, but because that was the only way they could get the votes in the first place. [The subsidies were extended for three years in 2022]. They were hoping that by the end of 2025 either Congress or the presidency would still be in Democratic hands and they could extend them, or the Republicans would change their minds and help vote to continue the subsidies. That's kind of where we are now.
We're seeing Republicans sort of slowly coming over. But you know, the Republicans have made it a point to oppose the Affordable Care Act since its inception. In his first term, President Trump tried very hard to repeal it, [but it] fell one vote short rather famously: the late Sen. John McCain turned thumbs down in a middle of the night vote. So, you've got a lot of Republicans who are now stuck between constituents who are very worried about their costs going up and their longtime disdain for this law in general.
Yeah, let's get a call. We've got Ashley on the line calling from St. Pete.
CALLER: I have been helping a lot of friends figure out what their options are given the recent changes to the Affordable Care Act. When the Affordable Care Act first came out, I actually worked as a health insurance agent for a year, and it's much different now. A friend who's in her early 30s has been self-paid for quite a few years. She doesn't get a subsidy. She was paying $700. The best policy we could find for her now was $1,200, but her out-of-pocket max went to $7,000. That's the best-case scenario of all of the friends I've helped so far.
What about that? That sounds like a pretty dramatic increase. Is that sort of what you're seeing? And what options are there for folks?
That is, unfortunately, fairly typical, and this is without a subsidy. People can drop down to a less generous plan, but then, as we've just heard, you'll be expected to pay more out of pocket before your insurance kicks in. It is difficult. A lot of people are simply going without insurance. They're looking for lower-cost ways to actually get care – to go to free clinics or community health centers. Hospitals and health care providers are very worried about people dropping coverage because then they're going to have to try and make up the difference. People are still going to come seeking care, and they're either going to be unable to pay their bills or providers are going to have difficulty collecting.
I believe we have James on the line.
CALLER: Me and my wife, we're both over 60, both self-employed. Our premium has gone from $1,200 last year up to $3,200 a month this year. It's just not doable. We’re not going to have insurance, and we're trying to negotiate cash prices for seeing our doctor. It’s just not sustainable for self-employed people. We've looked at options, catastrophic plans, but the coverage is so poor, and the deductibles – you know, at $20,000 it is just not worth buying.
Julie, what about that? I mean the notion that folks are just basically trying to negotiate cash deals for health care direct with their doctors. I mean, that does sound a bit extreme. Are you hearing other instances of that?
I am. In some cases, people are seeking out lower cost care, or they're seeking to get discounts if they have regular providers. But that's not really tenable in the long run. How long are those doctors going to be able to carry people who are paying less than they would even get from insurance. This is exactly the kind of person getting hit the hardest, the people not old enough for Medicare but old enough to be charged higher premiums.
And this is a real conundrum for Republicans, because a lot of these people are self-employed, they're small business owners, they're farmers and ranchers. They're people who tend to vote Republican. So, these people being hit the hardest are most likely Republican voters, which is, I think, why we're seeing so much turmoil here in Washington among Republicans about what to do about these subsidies.
How much does the Big Beautiful Bill – President Trump's spending package passed last year – factor into what's happening?
Well, there's almost $1 trillion in cuts to Medicaid and there are other changes to the Affordable Care Act that make it more difficult for people to get coverage. It has nothing to do with these subsidies; that was separate. But it will tend to lower the number of people with insurance overall – there'll be fewer people with Medicaid, there'll be fewer people on the Affordable Care Act exchanges. That puts more pressure on providers, on doctors and hospitals and clinics, who will suddenly have to scramble to continue to serve people who come to them needing medical care. That was one of the reasons that the provider community ended up supporting the Affordable Care Act back in 2010, because the idea of having more people with insurance means that they are more likely to get paid. So, there's a big concern about what this is all going to mean for the health system at large. So even if you don't have Medicaid or the Affordable Care Act insurance, if you lose your local hospital, that can impact you even if you have good insurance.
I want to get another call. You are on the air.
CALLER: Where does our lawmakers’ insurance come from? Do they participate in ACA?
That’s a great question. Julie, clarify that for us.
Actually, they do. During the debate on the Affordable Care Act in 2010, the Republicans insisted that if Congress was going to pass this bill, they were going to take part in it. So, members of Congress get their coverage through the Washington, D.C., small business exchange, part of the ACA. Congress does have to do this. Not all of the staffs have to do it, but many do.
So, are they in the lurch by these subsidies expiring?
Most members of Congress were probably not getting the subsidies; they earned too much, in most cases, to take advantage so that wouldn't affect them. But I haven't looked at how much coverage went up on the D.C. small business exchange.
