Do we understand what is happening to costs and the administration of our healthcare system because of the One Big Beautiful Bill Act (H.R. 1)?
On January 8, 2026, 16 House Republicans joined the Democrats in voting for a three-year extension of the Enhanced Health Insurance Tax Credits (EHITCs), but Senate Republicans allowed EHITCs to expire.
The expiration of EHITCs allowed by H.R.1 and Republican Senators refusal to extend them has led to the following consequences. Nationally, Kaiser Family Foundation (KFF) reported in late June that 2026 Affordable Care Act Marketplace enrollment is down thus far by 13%. ACA marketplace enrollment has dropped this year for the first time since President Trump’s first administration. As of February 2026, only 19.1 million people had enrolled in the ACA marketplace as compared to 22.1 million people in 2025, a dropoff of 3 million people. The reason? Americans who lost their EHITCs had their monthly health insurance premiums more than double on average. They increased 114% from $888 in 2025, to $1904 in 2026.
As a refresher, EHITCs were made law during COVID under the Biden administration. EHITCs extended the original ACA assistance that was provided for those earning less than 400% of the federal poverty level. The idea was based on sound economic opinion that if one had to pay more than 8.5% of their income on health insurance premiums, it would cause them great financial stress elsewhere. This year, ACA enrollees have had to pay 58% higher premiums and 37% higher deductibles.
A recent KFF survey focused on ACA marketplace enrollees for both 2025 and 2026. Health insurance premium increases were far and away the greatest reason for dropping health insurance or changing to a less expensive plan in 2026. Survey results showed 73% of enrollees are worried about affording medical care, 44% felt these increases would reduce their ability to pay for the basic necessities, e.g. food, clothing, utilities, rent, while 17% were concerned that they would not be able to afford their health insurance premiums through the remainder of 2026. Some experts predict that there could be further losses of ACA marketplace enrollment in 2026 to the tune of 17.5 million enrollees.
Charles Gaba, a healthcare financial accountant, has published ongoing changes in healthcare coverage on Substack. In his 7/27/2026 post, he reported that 48,000 Pennsylvanians have already lost their health insurance because their EHITCs expired. He further indicated that 430,000 unsubsidized ACA enrollees are facing 17% health insurance premium rates in the year ahead.
Those who authored H.R. 1 purposely delayed the implementation of the “work requirement” for Medicaid recipients until after the midterm elections this fall. This requirement’s objective is to save the federal government more than one trillion dollars over 10 years. The work requirement (really a paperwork requirement) requires low-income people without disabilities to prove they worked, volunteered or attended school at least 80 hours/month, or they lose their Medicaid.
68 million people receive Medicaid benefits; almost all are poor or disabled. The Republican stance is that this measure is to reduce “waste, fraud, and abuse”. The Congressional Budget Office predicts that 5 million will lose their Medicaid. Many of these people are working but are unable to complete the paperwork required by this law. The Center on Budget and Policy Priorities has estimated that two of three enrollees who will lose their Medicaid are truly eligible for it. States are responsible for implementing this requirement markedly increasing each state’s administrative burden. The only state that has tried the work requirement, Arkansas, cut 18,000 people from their Medicaid rolls in 2018 for failure to document their work. However, Arkansas saw no resultant increase in the number of eligible people working.
As of now, a person who needs Medicaid can get it initially for the first 90 days while they complete the paperwork proving their eligibility. As of 2027, someone that needs Medicaid will have to show proof of compliance for at least one month, but up to 3 months at the discretion of the state prior to receiving Medicaid.
By 2034, 14 million Americans will have lost their Medicaid benefit. If you add those who will lose their health insurance due to the expired EHITCs, approximately 50% of the population who gained healthcare coverage through the ACA will have lost it.
Republicans have made decisions, votes and laws that result in loss of healthcare coverage for millions of Americans.
I was a registered Republican for most of my life. Throughout my life, both Republicans and Democrats have had good and bad ideas. I believe that both the sudden expiration of EHITCs and the upcoming “work requirement” for Medicaid benefits are both bad ideas and should be improved upon as soon as possible to make healthcare more affordable for these affected persons.
