The fate of Obamacare rests on the outcome of a few key Congressional races. Here's what could transpire next.

• Despite the abandonment of plans to repeal the Affordable Care Act by Republicans and former President Trump, they still have a distinct vision for the program's future that differs significantly from Democrats.
• The health care law's enhanced subsidies and its progress to expand Medicaid coverage are at risk in the November elections.

The Affordable Care Act has long been the target for repeal and replacement by the Republicans.

These days, not so much.

"In March, former President Donald Trump stated in a Truth Social post that he was not running to terminate the ACA. During the Sept. 10 presidential debate, Trump reiterated that he did not intend to eliminate the program. However, he added that he would only do so if he could come up with a plan that would cost less money and provide better healthcare than Obamacare."

In Oct. 2016, the candidate stated that real change starts with immediately repealing and replacing the disastrous Obamacare.

The Affordable Care Act (ACA) has gained significant support among Americans, with around 60% of them holding a positive view of the 2010 health care law, according to a recent KFF poll. Additionally, a record number of people, over 20 million, enrolled in coverage on the ACA marketplace in 2024.

Despite the decline of existential threats to the program, Republicans and Democrats remain divided on the future role of the health care law, according to Cynthia Cox, vice president and director of the program on the ACA at KFF.

"There are diverse interpretations of what constitutes improvements to the ACA, as one person's enhancement may be another person's weakening, according to Cox."

If the White House is taken by a different party and majorities in the House and Senate are won by different parties in November, what could happen to Obamacare?

Dems would push to expand subsidies

If Democrats maintain their slim Senate majority or capture the House from Republicans, they will prioritize extending the ACA's increased subsidies, according to Cox. The government-funded assistance, which was initially enacted during the pandemic under the American Rescue Plan in 2021 and later extended in the Inflation Reduction Act in 2022, will expire at the end of 2025.

Harris has stated that she intends to maintain the financial assistance that has substantially reduced the cost of coverage for individuals purchasing plans on the ACA marketplace. According to Cox's estimate, an individual earning $60,000 a year now pays $425 per month for premiums, compared to $539 before the enhanced subsidies. Similarly, a family of four earning about $120,000 currently pays $850 per month instead of $1,649.

Cox stated that it is uncertain whether the subsidies would be renewed if someone else wins the elections.

A spokesperson for the Harris campaign, Joseph Costello, stated that the vice president wants to keep the enhanced subsidies in place.

According to Costello, Vice President Harris is striving to enhance healthcare and reduce expenses, and her strategy involves establishing enduring tax credits that are decreasing health insurance premiums by an average of approximately $800 per year for countless Americans.

On Monday, the Harris campaign released a report depicting a grim outlook for healthcare under a potential Trump administration. The report was based on the conservative blueprint Project 2025, which Trump has disavowed, and a full repeal of the ACA, which Trump has somewhat backed away from. Despite this, the report cautioned that under the most extreme policies, approximately 500 rural hospitals could shut down and millions of Americans could lose their health insurance.

The Trump campaign did not reply to a request for comment.

If Democrats manage to retain the increased subsidies, they may focus on providing further relief to marketplace policyholders, according to Cox. High deductibles remain a significant issue, with the average ACA plan deductible exceeding $3,000 in 2024, and some plans having deductibles of over $7,000, as found by KFF.

Cox suggested that Democrats may find additional interest in increasing subsidies for cost-sharing assistance to lower deductibles.

The 10 states that have not expanded Medicaid under the ACA are likely to be a focal point for Democrats, according to experts.

Under the Affordable Care Act, the federal government mostly funds states' efforts to broaden their eligibility for free health insurance. However, in 2012, the Supreme Court determined that Congress had overstepped its constitutional authority by mandating states to expand Medicaid, one of the primary ways the law aimed to increase coverage rates.

Democratic lawmakers could motivate the states that have not expanded Medicaid coverage, such as Texas, Wyoming, and Florida, to do so by bridging the funding gap, according to Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University's McCourt School of Public Policy. Currently, the federal government covers 90% of the state's expansion costs.

Mark Duggan, The Wayne and Jodi Cooperman Professor of Economics at Stanford University, stated that convincing the 10 states would aid millions of people in obtaining affordable medical care.

Republicans may try to slash program costs

Cox stated that Republicans and Trump often criticize the ACA for being expensive, but their main concern is the financial burden on taxpayers.

"The debate often centers on whether it is the federal government or those who are sicker or uninsured that should spend the money."

If Republicans retain control of either the House or Senate, the easiest way to lower the cost of the program would be to let the enhanced subsidies expire, she stated.

According to an estimate by the Congressional Budget Office, the cost of permanently extending enhanced subsidies is approximately $25 billion per year.

Republicans are concerned about extending them, according to Cox.

If the aid is dropped, approximately 3.8 million individuals will lose their health insurance, and those who keep their coverage may have to pay higher premiums, according to the Congressional Budget Office's estimate.

Experts predict that GOP lawmakers and Trump may target the ACA's expanded Medicaid coverage for cost-cutting measures.

KFF's Robin Rudowitz stated that recent GOP proposals aim to reduce federal funding for Medicaid to states, potentially lowering the federal funding match rate for extended coverage from 90% to 50%.

If this cost shift is large, states may have to make tough choices to limit coverage, resulting in many people in the expansion group not having affordable options and potentially being uninsured, according to Rudowitz.

The previous administration increased the availability of non-ACA compliant health insurance options, including short-term plans, experts say. If Republicans gain big in November, it's likely to happen again.

Supporters of these plans argue that they enable insurers to provide lower monthly premiums to consumers by not mandating coverage of as many services. However, these plans can also deny or charge more to individuals with pre-existing conditions. During Trump's presidency, enrollment in short-term plans increased significantly.

The ACA's proponents are concerned because these plans "draw away" younger and healthier individuals from the marketplace, according to Corlette.

"The risk is that the ACA plans will only serve sick people, leading to an unsustainable insurance market, and over time, premiums will continue to increase."

Sen. JD Vance, the Republican vice presidential nominee, has suggested a health care system similar to the one Corlette has expressed concern about.

Vance stated at a September rally in Raleigh, N.C. that regulatory reform in the health care system will be implemented, allowing individuals to select a plan that suits their needs.

The Ohio senator stated that individuals with comparable health circumstances should be placed in the same risk pools.