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What the House did
The vote followed a discharge petition that let supporters force the bill to the floor over the objections of House Republican leaders. All Democrats were joined by 17 Republicans. The enhanced credits expired at the end of 2025 after the fall shutdown ended without a deal, and enrollees are now seeing much higher premiums.
The Congressional Budget Office estimates the three-year extension would add about $80.6 billion to deficits over ten years. It projects the number of insured people would rise by about 100,000 in 2026, 3 million in 2027 and 4 million in 2028. The small effect this year reflects that open enrollment decisions for 2026 are largely made.
Why the Senate is the real test
The Senate does not have to take up the House bill and rejected a three-year extension last month. A bipartisan group of senators is working on an alternative. Ideas under discussion include a two-year extension, income caps for higher earners, a small minimum monthly premium and expanded health savings accounts. Majority Leader John Thune has said any plan needs income limits, a nominal premium and some HSA expansion. Abortion coverage rules remain unresolved. President Trump has favored sending money directly to people for health savings accounts, an approach most Democrats reject.
Even if a compromise passes, it would likely be narrower than the House bill and would arrive after many people have already dropped coverage or moved to cheaper, higher-deductible plans.
What hospital leaders should do
- Keep the base case conservative. Budget for higher self-pay volume and more bad debt among former marketplace enrollees through 2026. Treat any extension as upside.
- Watch deductibles, not only coverage. Patients who stay insured but switch to bronze plans will owe more at the point of service, which raises collection risk.
- Strengthen financial counseling. Screen self-pay patients for Medicaid and charity care eligibility early, and make sure marketplace enrollees know about any special enrollment options.
- Give lawmakers local numbers. Senators weighing a compromise respond to data on uninsured visits, emergency department use and uncompensated care in their states.
Archive entry for Jan 9, 2026, added Nov. 11, 2026.