On January 31, Open Enrollment on the Affordable Care Act (ACA) Marketplaces officially ended in every state. This marks yet another milestone without federal action to address a health care affordability crisis that went into overdrive at the start of the year. Because Congress did not prevent enhanced premium tax credits (ePTCs) from expiring on December 31, average out-of-pocket monthly premiums for households with ACA coverage will more than double this year. As anticipated in an earlier blog, monthly costs are spiking even more dramatically for older people, residents of rural areas, and middle-income households with incomes just over the PTC eligibility “cliff” (about $64,000 for a single person).
That could have been the end of the story. But enrollees and advocates fought on.
After months of sustained advocacy – driven by the real stories of people confronting premium bills set to double, triple, or more – the House of Representatives passed a three-year extension of ePTCs on January 8, 2026. 230 Representatives supported the bill by a margin that was both wider and more bipartisan than expected. This was a huge and necessary victory, but the Senate must act before the extension becomes law.
Although the Senate rejected a clean extension in December, it could choose to pass the House-approved version at any time. State Marketplaces have indicated that reinstating ePTCs is not only doable, but a scenario for which they have planned. But instead of taking action to quickly cut out-of-pocket premium costs in half, a group of Senators dithered behind closed doors for weeks to draft their own version, all while millions of enrollees counted down the final days of Open Enrollment.
Now that the draft Senate proposal is out, we know that it wasn’t worth the wait. Not only does the proposed extension expire by the end of 2026, the package would impose minimum premium payments on ACA coverage for the first time since the law was implemented; alter funding for cost-sharing reductions in such a way that lowers PTCs and thereby increases costs for many enrollees; and appears to exclude all lawfully-present noncitizens from accessing PTCs, an approach that is even harsher than draconian anti-immigrant provisions in the so-called “One Big Beautiful Bill Act”. Neither side of the ePTCs debate appears to have embraced the proposal, suggesting that a legislative solution is not imminent.
So, is this the end of the road for ePTCs? The fight for Marketplace affordability is certainly entering a new phase. Now, households are truly contending with the predictable, harmful outcomes of allowing ePTCs to expire. The Centers for Medicare & Medicaid Services (CMS) reported that at least 1.2 million fewer people made plan selections as of January 15, 2026 compared to the same date last year. These numbers are deeply troubling, yet still do not yet show the full impact of the premium spikes, since a “plan selection” in early data does not equate to a full plan effectuation (which requires premium payment). One sign that enrollment is likely to fall further is that plan selections for new enrollees were down a startling 14% overall, but renewing enrollee enrollment was down just 3%. In 2025, 10.8 million renewing enrollees relied on automatic re-enrollment, meaning that they remained enrolled in current coverage without actively selecting a new plan. If that trend holds for 2026, millions of people may not have been aware that their plan had doubled or more in price; others may have re-upped their coverage anticipating that Congress would ultimately extend ePTCs. These enrollees are counted as having made a plan selection, but it will be months before data show how many people actually retained coverage. State-based Marketplaces have also reported that both new and renewing enrollees are more frequently selecting bronze coverage with lower premiums but higher deductibles and cost sharing, showing that people are dropping to lower-value coverage in the face of higher premiums.
However, states that provide state-based subsidies for residents represent one potential silver lining. At least 10 states are providing state-funded support for Marketplace enrollees in 2026, including several who initiated or expanded programs specifically to counteract federal funding cuts. New Mexico, which fully replaced ePTCs for residents in the most generous state-based program in the nation, reported a 17.1% increase in plan selections. Like many of the programs created to respond to the ePTCs crisis, however, New Mexico’s subsidies are temporary and will need to be renewed at state cost if ePTCs are not reinstated.
Opponents of the ACA may hope that enrollees will simply accept dramatic cost spikes and coverage losses. But the history of the last few months suggests that enrollees and advocates are unlikely to accept defeat on this issue. People with ACA coverage made premium affordability a headlining issue for months in 2025, driving the longest federal government shutdown in history and keeping up the pressure on the House until an extension passed despite leadership hostility. So, what’s next?
Keep Urging Senators to Support a Clean ePTC Extension. Reinstating ePTCs at the level enrollees have relied on since 2021 is the only solution to drive premium costs down dramatically and quickly. Policies like those promoted by some in the Senate – premium penalties, reduced PTCs, and exclusions for lawfully-present people – would increase the cost of comprehensive health coverage for most people and would vastly increase the operational complexity of reinstating ePTCs. Advocates should continue to urge Senators to take up and pass a clean ePTC extension, rather than a short-term extension in exchange for permanently weakening the ACA.
Encourage State Leaders to Take Charge of Marketplace Affordability. While federal legislators have thus far failed to take action to support ACA consumers, some states have stepped up to the plate with state-based subsidies for some or all ACA households. States that already have a state-funded subsidy should consider expanding it to protect all households, following the New Mexico model. Many states, including New Mexico and Maryland, are providing state support on a temporary basis in 2026. While this approach was understandable when it seemed that Congress was moving to a compromise on ePTCs early in the year, advocates should encourage state leaders to consider how to extend this funding in the face of Congressional inaction. States that have not yet funded a state-based subsidy have many examples to draw from, such as the program in New Jersey that has provided premium support for households separately from ePTCs since 2021.
Uplift Personal Stories That Illustrate the Impact of Policy Choices – Both Positive and Negative. More data are needed to fully assess the effects of federal and state policies on coverage nationwide. But advocates need not wait to highlight the individual harms they see in their communities or the benefits of policies like state subsidies, which must continue to be funded as long as Congress fails to extend ePTCs. Continue to document and uplift personal stories with state officials and legislators, your Congressional delegation, and the media.
