Opinion: Congress Had Two Chances to Stop This Year's Health Premium Shock. It Took Neither.

Open enrollment for 2027 health coverage begins in Idaho on Oct. 15 and in Georgia on Oct. 19, with most of the rest of the country following on Nov. 1 under HealthCare.gov's published enrollment calendar. What shoppers will find when they log in is not a surprise. It is the predictable result of two choices Congress made, and then made again, over the past year: to let enhanced Affordable Care Act subsidies lapse, and then to decline, on a recorded vote, to revive them. The premium increases now showing up in insurers' own rate filings are not an accident of the market. They are the price of a deliberate decision, confirmed twice, to do nothing.

That is worth saying plainly because the coming round of sticker shock will be described in the press, and by some in Washington, as simply what health insurance costs these days. It is not simply that. According to an updated analysis by KFF of 276 insurers' publicly filed rate requests across all 50 states and the District of Columbia, insurers are seeking a median premium increase of 15 percent for 2027, the second consecutive year of double-digit hikes after a median finalized increase of 20 percent for 2026. Insurers themselves attribute a meaningful share of this year's increase to a specific, identifiable cause: the expiration of the enhanced premium tax credits that had kept the individual market more affordable since 2021. KFF's review of detailed filings found insurers crediting roughly four percentage points of their 2027 rate requests directly to the subsidy expiration and the sicker, smaller risk pool it has left behind.

The Numbers Behind the Sticker Shock

The effect on individual households is not abstract. KFF calculates that a 40-year-old Indiana resident earning $65,000 a year and enrolled in a benchmark silver plan would pay roughly $546 a month in 2027, compared with $316 a month in 2025 when the enhanced credits were still in effect — a jump of more than 70 percent for the same coverage. That is the arithmetic of what happens when a subsidy that scaled with income simply disappears for people who earn too much for the old, pre-pandemic subsidy formula but not enough to shrug off a several-thousand-dollar annual increase.

The market-wide numbers tell the same story from a different angle. The Centers for Medicare & Medicaid Services reported that 23.1 million people selected marketplace coverage for 2026, a total the agency fairly describes as near a record high in absolute terms. But KFF's state-by-state review found that enrollment fell in every state except New Mexico, the only state that fully replaced the expired federal subsidy with its own money. It was the first nationwide marketplace enrollment decline in seven years, arriving in the same year costs rose fastest. CMS's own national snapshot of the 2026 open enrollment period shows the shift underneath that headline number too: enrollees moved toward cheaper, skimpier bronze plans and away from silver, a classic sign of people priced out of the coverage they would otherwise choose.

How Washington Chose This Outcome

None of this happened because no fix was on the table. The enhanced subsidies, first enacted in the 2021 American Rescue Plan Act, were always scheduled to expire at the end of 2025 absent new legislation. That deadline was precisely what drove the 41-day federal shutdown that began in October 2025, which ended only when a handful of senators accepted a deal: reopen the government in exchange for a guaranteed floor vote on extending the credits. Congress kept that procedural promise. It did not keep the substantive one. On Dec. 11, 2025, the Senate took up competing bills — a three-year extension backed by Democrats and an alternative built around health savings accounts backed by Republican leadership — and, as PBS NewsHour reported live from the floor, both failed on identical 51-48 votes, nine short of the 60 needed to advance. Four Republicans — Susan Collins of Maine, Josh Hawley of Missouri, and Lisa Murkowski and Dan Sullivan of Alaska — crossed over to back the Democratic extension, a margin that came close enough to matter without being close enough to pass.

"The bottom line is we have got to help the American people with their health care costs," Sen. Josh Hawley said after the vote, in remarks captured as part of NPR's accounting of how the subsidy fight collapsed in Congress.

Hawley's own vote for the extension, and his party's decision to let the bill die anyway, is the clearest evidence that this was not an unavoidable outcome. A workable bipartisan floor existed in the Senate in December. It simply was not enough votes, and leadership on both sides let the session end without another attempt.

Who Pays, and Who Didn't Have To

It is fair, and necessary for an honest accounting, to note that insurers do not blame the subsidy expiration alone. KFF's filing review found that underlying medical cost growth — hospital and physician prices, drug costs, general inflation in health care labor and services — remains the larger driver of 2027's increases, with the subsidy-related risk-pool effect layered on top of that baseline. Republicans who opposed extension also made a coherent fiscal argument: the enhanced credits were enacted as emergency pandemic relief, cost tens of billions of dollars a year to maintain, and had expanded well beyond their original income caps to subsidize people earning six figures. Those are legitimate considerations for how a permanent subsidy structure should be designed, including income limits, fraud safeguards and sunset provisions — all ideas raised, and rejected, in the competing Senate bills.

But a legitimate design debate is not the same thing as the outcome Congress actually produced, which was no subsidy structure at all rather than a better one. The people absorbing the gap are concentrated in a specific, identifiable group: self-employed workers, early retirees, gig workers and small-business owners who earn too much for Medicaid and too little to treat a $2,000-a-year premium increase as a rounding error. They are not a sympathetic abstraction in a budget memo. They are the marketplace's core customer base, and the CMS and KFF data both show them responding exactly as price-sensitive consumers do: buying less coverage, or none.

A Fix That Keeps Getting Postponed

There is no deadline forcing Congress's hand again before the 2027 plan year is locked in. That is precisely the danger. The shutdown deadline and the December floor vote both created real pressure to act, and both were allowed to pass without a resolution. Absent another forcing event, the enhanced-subsidy debate risks becoming an annual ritual of warnings, filings and after-the-fact news coverage rather than a policy that gets settled.

The better course is the one the December votes gestured toward but did not reach: a narrower, means-tested extension, with firmer income caps than the pandemic-era version and a legislated sunset tied to actual cost data rather than a cliff that forces insurers to file rates before anyone knows what subsidy, if any, will exist. Collins, Hawley, Murkowski and Sullivan already showed that votes for something like this exist in the Senate. What has been missing is a bill, and a timeline, that turns four votes into sixty before the next open enrollment period arrives rather than after.