Representative Katherine Clark, a Democrat from Massachusetts, during a rally for healthcare funding with Democratic lawmakers outside the US Capitol in Washington on Sept. 30. Photographer: Graeme Sloan/Bloomberg
(Bloomberg) — The health insurance subsidies at the center of the US government shutdown fight disproportionately benefit areas of the country represented by Republican lawmakers, posing a potential vulnerability for President Donald Trump’s party in next year’s midterm congressional elections.
Twelve million Americans in Republican-held US House districts are covered by health plans purchased through Affordable Care Act exchanges versus nine million living in Democratic-held districts. Of the 75 districts where at least 10% of the people are enrolled in Obamacare policies, 47 are represented by Republicans in the House, according to 2024 data compiled by KFF, a nonpartisan health research foundation.
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The disparity helps explain the political rationale for Democrats to focus attention on their demands to renew Obamacare subsidies set to expire at the end the year. It also likely contributes to some Republican lawmakers’ eagerness to find a way to extend the subsidies, even if they don’t want to give Democrats a shutdown victory.
“It is districts in deep red states that have the highest ACA enrollment,” said Larry Levitt, executive vice president of health policy at KFF. “A big part of the MAGA coalition” benefits from the insurance subsides, including small business owners, farmers and workers in jobs without employer-provided coverage, he added.
Ironically, that’s in part because of Republican office-holders’ hostility to the health insurance program started by Democratic President Barack Obama. Republican-run states, particularly in the South, rejected the federally subsidized Medicaid expansion available under Obamacare so more residents receive coverage through ACA policies.
‘Supercharged’
The enhanced premium tax credits adopted during the Covid-19 pandemic “supercharged” Obamacare enrollment, Levitt said.
Obamacare subsidies are broadly unpopular among Republican lawmakers, who see the assistance as too costly and bolstering an expanded government role in health care, as well as closely associated with a Democratic president. A permanent extension of the enhanced premium credits would cost $350 billion over 10 years, according to the nonpartisan Congressional Budget Office.
Democrats are already incorporating the expiring tax credits into a broader campaign message to voters, blaming Republicans for rising health-care costs. While the Medicaid cuts Trump incorporated into his signature tax law won’t take effect until after the midterm elections, voters will feel the impact of the lost Obamacare subsidies soon.
Democrats are seeking to replicate their success in the 2018 midterms during Trump’s first term, when they ran against GOP efforts to repeal the Affordable Care Act, flipped 40 seats and retook control of the House.
The risk to Republicans is that Democrats persuade voters a spike in Obamacare premiums driven by expiration of the subsidies is the “first tranche of Republican health-care cuts,” said Dean Rosen, a former senior Republican Senate aide who is now a partner at Mehlman Consulting, a lobbying firm with health-industry clients that benefit from broader insurance coverage.
“If so, this is something that will bite in a real way prior to the midterms,” he added.
Representative Katherine Clark, a Democrat from Massachusetts, during a rally for healthcare funding with Democratic lawmakers outside the US Capitol in Washington on Sept. 30.Photographer: Graeme Sloan/Bloomberg
Without the subsidies, premiums on average are expected to jump 114%, according to KFF. That could be more dramatic for older Americans, especially in rural areas where there’s less competition from health care providers to put a check on costs. Without the subsidies, 4 million people will lose health coverage, the nonpartisan Congressional Budget Office forecasts.
Amy Bielawski, a 60-year-old small business owner in Tucker, Georgia, is among them. The subsidies lowered her current health insurance premiums to about $30 a month.
Bielawski, who had been uninsured for most of her life until the enhanced premium tax credits began in 2021, runs Hare-Brained Productions, which provides entertainers for parties and events. She relies on insurance to cover doctors’ visits she needs to get prescriptions for a thyroid disorder.
“If it goes up to 100 bucks a month that’s probably going to put me over the edge,” Bielawski said.
WATCH: The US government shutdown extended to a third day while lower-level negotiations have failed to strike a deal. Laura Davison reports.Source: Bloomberg
‘Engaged Constituency’
Bielawski’s home state is shaping up to be one of the key battlegrounds in the 2026 midterms, with Senator Jon Ossoff, a Democrat, defending his seat in a state Trump won by 2 percentage points last November.
Senator Raphael Warnock of Georgia, who’s also a Democrat, remarked on Friday that the burden could fall on areas represented by GOP lawmakers. “A lot of this pain will be felt in their districts,” he said. “This is really not a Democrat and Republican issue.”
Democrats are already running online ads in 35 Republican-held House districts they’re targeting next year, blaming Republicans for rising health-care costs.
In at least eight districts the nonpartisan Cook Political Report has rated as “toss-ups” in 2026, ACA enrollment as a percentage of the population exceeds the 2024 vote margin. That includes races in Arizona, Nebraska, Pennsylvania, Colorado and Iowa.
“This will be a very engaged constituency,” Levitt said.
It’s also possible the issue could force Republicans to defend typically safe seats, Levitt said, pointing to Texas and Florida.
Each of Florida’s 28 congressional districts, the majority of which are held by Republicans, have more than 10% of their residents enrolled in ACA exchanges. Enrollment exceeds 30% in five Florida districts, three of which are represented by Republicans, according to KFF data.
An Obamacare sign outside an insurance agency that offers plans under the Affordable Care Act, in Miami in 2021.Photographer: Joe Raedle/Getty Images
Two of those Republicans, Representatives Maria Elvira Salazar and Carlos Gimenez, are teaming up with a bipartisan group pushing for a one-year extension of the tax credits. The group, led by GOP Representative Jen Kiggans of Virginia, comprises swing-district lawmakers like Kiggans, as well as members from comparatively safe seats with high ACA enrollment.
A 64-year-old making $63,000 a year in Gimenez’s and Salazar’s districts would see premiums for a mid-tier silver plan jump at least 170% from current levels to more than $1,200 a month, according to KFF’s data tool.
Extending the tax credit would mean “providing critical relief and ensuring millions of families can keep their coverage without facing massive cost increases,” Gimenez said in a statement. Salazar’s office did not respond to a request for comment.
Baked In
Still, most Republican lawmakers oppose extending the subsidies.
Republicans, especially those in safe seats, may see Democrats’ attacks on health care as already baked into the political equation, Mehlman’s Rosen said.
“They know that Democrats are going to spend millions of dollars in the midterms beating them up on health care,” Rosen said, of Republicans’ political calculus. “Do I really want to sit down and spend tens of billions of dollars if I’m still going to get whacked by all these ads for cutting trillions in Medicaid?”
(Updates with Warnock, in 17th paragraph.)
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