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Unless the Trump administration and Republicans in Congress act quickly, millions of working Americans could lose access to their health insurance at the end of this year. Among the most affected will be small businesses and middle-income earners — many of whom, ironically, live in congressional districts that vote Republican. An estimated 4.7 million small business owners and self-employed workers relied on the Affordable Care Act marketplace to obtain health insurance in 2023, according to the latest figures from the Treasury Department. But the tax credits these businesses use to offset their health insurance costs are set to expire at the end of December — and neither the Trump White House nor Republicans in Congress are poised to do anything about it. That will inflict real pain on millions of Americans and hand Democrats an issue they can use to bludgeon Republicans in the midterms. Health care remains one of Democrats’ few potent weapons. The reason for the December deadline is that, in 2021, Congress raised the income levels of people who could receive the enhanced tax credits at the urging of President Joe Biden. The Inflation Reduction Act extended the subsidies until 2025. The changes came with a hefty federal price tag — estimated at $335 billion over 10 years — but they also led to record-high enrollment in the ACA marketplaces. In 2024, more Americans had health insurance than ever before. Unfortunately for Biden, most of the public heard little about this program, according to KFF, a nonprofit health policy research organization. Half of the recipients are not even aware their health insurance is subsidized with federal dollars. And many of the beneficiaries are Republican. According to a review by KFF, 56% of ACA marketplace enrollees live in congressional districts represented by Republicans and 76% of enrollees are in states won by Donald Trump in the 2024 election. Should the credits disappear, states will see a $34 billion reduction in state gross domestic product, lose an estimated 286,000 jobs — nearly half of them in hospitals, doctors’ offices and pharmacies — and state and local tax revenue will decline by $2.1 billion, according to a report released in March by the Commonwealth Fund and the George Washington University Milken Institute School of Public Health. The hardest-hit states would be those that have not expanded Medicaid, where residents depend more on marketplace subsidies — Alabama, Florida, Georgia, Indiana, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. All voted for Trump in 2024. For the people who rely on the subsidies, the impact will be immediate, painful and disruptive. Out-of-pocket premiums for ACA marketplace enrollees will increase by an average of more than 75%, according to an estimate by the Petersen-KFF Health System Tracker. Middle-income families (calculated as $103,280 for a family of three) will lose up to $5,370 a year in premium tax credits, forcing many to go uninsured. “There’s not a lot of gray area here,’’ said Mary Mayhew, CEO of the Florida Hospital Association. “We will see our uninsured rates increase significantly for individuals who are largely working.” Mayhew is the former secretary of the Florida Agency of Health Care Administration, the former commissioner of the Maine Department of Health and Human Services and worked in the first Trump administration’s Medicaid office before coming to Florida. For years, she fiercely opposed the expansion of Medicaid under Obamacare, arguing that the federal government shouldn’t be involved in subsidizing private insurance. Now, as head of Florida’s largest hospital association, Mayhew has changed her mind. Her association has teamed up with other business groups to form Florida Conservatives for Affordable Care, a coalition lobbying Congress to extend the subsidies. “It really does come down to, if not this, then what?’’ Mayhew told me. “The market has changed” and without the federal program, it would be “incredibly difficult for a small business to purchase health insurance coverage for their employees.” The about-face over the ACA from many business groups is striking, but their argument is no surprise, said Leighton Ku, director of the Center for Health Policy Research at the George Washington University Milken Institute School of Public Health. The marketplaces were designed to appeal to conservatives by allowing people to buy health insurance through private plans. Since 2014, when the marketplace launched, the ACA has halved the number of people without insurance, according to the most recent data. Businesses now have the flexibility to hire part-time and seasonal workers who can qualify for individual coverage. Entrepreneurs, early retirees and young adults are guaranteed coverage — and often receive it with federal subsidies depending on their income level. Mayhew says she is urging Congress to “set aside the polarizing politics of the Affordable Care Act” and realize that small businesses are in better shape now than they were 15 years ago because they have better access to health insurance. “You can’t simply be ‘no’ to everything,’’ she says. “This is working.” That’s good advice. Will Republicans take it? If not, they may be handing Democrats a Christmas gift. Mary Ellen Klas is a columnist for Bloomberg Opinion. You can send letters to the editor to [email protected].

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