Is Congress Letting Insurance Premiums Soar?

On July 4, 2025, President Trump signed H.R. 1 into law, a sweeping budget reconciliation bill that includes deep cuts to Medicaid and nutrition assistance programs. Most critically for the Affordable Care Act (ACA) Marketplace, the bill fails to extend the Enhanced Premium Tax Credits (EPTCs) that have made health insurance affordable for millions of working families across the country.  

These premium tax credits were introduced during the pandemic through the American Rescue Plan and extended by the 2025 Inflation Reduction Act. They keep monthly premiums affordable for 92% of people purchasing their coverage through the Marketplace. Without Congressional action to extend them, the EPTCs will expire at the end of this year and send health premiums soaring.  

The consequences will be felt nationwide, but in states like Tennessee, where Medicaid has not been expanded, the fallout could be especially severe. The numbers are stark. In Tennessee alone, an estimated 265,000 people could lose their health insurance altogether if the EPTCs are not extended. Another 46,000 will face dramatically higher premiums. The state’s uninsured rate is projected to rise by a staggering 39%.  

The national picture is just as alarming. The Congressional Budget Office estimates that, without an EPTC extension—and combined with other structural cuts to Medicaid and CHIP—up to 15 million Americans could become uninsured by 2034. And as new research from KFF shows, premium costs for Marketplace plans could as much as double for some. For example, a 27-year-old earning $35,000 a year could see premiums for a benchmark silver plan rise more than 150%, jumping from roughly $1,000 annually to over $2,600. For some low-income enrollees who currently pay zero dollars out-of-pocket, monthly premiums could reappear overnight. Middle-income families who currently benefit from caps on premium contributions could lose that protection, facing full-price plans that cost thousands of dollars a year. Even those who remain eligible for some form of assistance will see their subsidies shrink, forcing them to pay more for less coverage. KFF also notes that uncertainty around the future of EPTCs is already contributing to projected 2026 premium hikes—beyond what would be expected from normal medical inflation. 

For Jesse Call of Donelson, Tennessee, these statistics are more than numbers. As a case manager at The Village at Glencliff, a nonprofit in Nashville that provides medical respite care for people experiencing homelessness after hospital stays, Jesse sees daily what happens when people fall through the cracks of the healthcare system. 

His work is deeply personal. Jesse has carried a passion for serving people experiencing homelessness since high school, shaped in part by his own experience with housing insecurity. Now, at Glencliff, he supports medically vulnerable individuals who would otherwise have no safe place to recover. “I just want to show people that they’re cared for,” Jesse says. “Even if they’re in a tough spot.”  

The work is meaningful. However, like many small nonprofits, Glencliff can’t afford to offer traditional employer-sponsored health coverage. Instead, the organization provides a $500 monthly stipend to help employees purchase other plans. 

The stipend currently covers Jesse’s gold-tier plan, with the help of a standard subsidy that reduces his monthly premium by around $200. “Most of us on the Marketplace are just trying to have a basic level of health insurance,” Jesse says. “So we can pick up a prescription at Kroger without it costing hundreds of dollars.” 

His plan allows him to afford preventative care and cover medication that would otherwise cost over $2,000 a month. But if premiums rise due to the loss of EPTCs, Jesse may have to consider downgrading his plan. “That means higher co-pays and less coverage,” he says. “I could afford to keep my current plan—but it would be really hard. I’d probably have to look into charitable healthcare.” 

Jesse receives the enhanced premium tax credits and sees the impact in the lives of the people he serves. Recently, he worked with a woman battling leukemia who lost her TennCare coverage after qualifying for Social Security Disability Insurance (SSDI). Her new SSDI income pushed her just above the Medicaid threshold but wasn’t nearly enough to afford private insurance. Jesse helped her enroll in a Marketplace plan with a low premium that kept her covered.  

This is the reality for thousands of Tennesseans who live in the gap between Medicaid eligibility and the ability to pay full-price premiums. And if premiums rise due to the expiration of EPTCs, the damage won’t just be individual. Healthier people will begin to opt out of coverage because of cost, leaving a sicker and more expensive insurance pool behind. That dynamic, known as adverse selection, can lead to what experts call a “death spiral,” where premiums rise so rapidly that the entire ACA Marketplace becomes unstable. 

“Most of us are working. Most of us have employers who can’t afford to offer insurance,” Jesse says. The ACA Marketplace supports small business employees, nonprofit workers, freelancers, and gig economy professionals and more —people who are doing their best to stay covered. 

Congress has the power to stop this looming crisis. By extending the Enhanced Premium Tax Credits, lawmakers can keep coverage affordable for millions of Americans.