For months, state insurance regulators (PDF), state Marketplace directors, and a wide range of health care stakeholders (PDF) have urged federal policymakers to extend the expiring premium tax credit (PTC) enhancements that have made health insurance more affordable for millions of Americans. Now, with open enrollment for 2026 in full swing, premium increases are being felt by Americans nationwide. 

In the past week, reporting has indicated that the White House will soon release its own proposal to extend the PTC enhancements. Details are scarce, and the plan is reportedly in flux. But reports suggest it may combine a two-year partial extension with new PTC reductions and barriers to enrollment.

The effects of any such proposal on Americans’ health care will largely turn on the following six issues:

• timing
• net effects on affordability and coverage
• duration of proposals
• deductibles
• preexisting condition protections
• additional measures

As we await details of the administration’s proposal, here are six questions policymakers should ask. 

1. Timing: Does the proposal address the higher premiums people are facing right now?

The deadline to enroll for January Marketplace coverage is December 15, and already, millions of people have learned their out-of-pocket premiums are doubling on average because of the enhanced PTCs expiring. Every day, more people decide not to enroll or cancel their automatic reenrollment because of the premium increases. 

Although numerous options could be considered in the medium term to reduce premiums or reform the health care system more broadly, the only workable option to address immediate premium increases for 2026 is extending the enhanced PTCs in their current form. That’s because operationalizing changes in Marketplace policy requires months to build, test, and deploy new IT systems. Establishing and transferring funds to health savings accounts (HSAs) would take even longer. 

Fortunately, Marketplaces have already built IT systems for a “clean” extension (i.e., an extension of the enhanced PTCs in their current form). Many could switch these systems “on” in a matter of days. Any proposal that does not include a clean extension for 2026 cannot address the immediate affordability problem.

2. Net effects on affordability and coverage: Do the proposal’s PTC reductions substantially increase out-of-pocket premiums, even to the point of reducing coverage beyond current 2026 policy?

If the proposal extends enhanced PTCs but also includes new reductions, it would weaken the enhancements’ ability to mitigate coverage losses. Depending on the specific reductions included, these changes could eclipse the benefits of enhancement extension entirely and result in a net coverage loss relative to current 2026 policy. Reports suggest the proposal may:

• Set a premium contribution floor at 2 percent of income. This would largely eliminate the enhancements for the lowest-income families and reduce them for everyone with incomes under 200 percent of the federal poverty level (FPL; 200 percent of FPL is about $31,000 for an individual)—a group that represented 63 percent of enrollees in 2025.
• Prohibit zero-premium coverage. A Brookings analysis found that a $1 premium floor would cause nearly 1 million people to drop coverage. This goes beyond eliminating the enhancements, as 14 percent of enrollees (PDF) paid no premium before the enhancements took effect by enrolling in a lower-cost plan.
• Appropriate cost-sharing reduction payments. This change would reduce PTCs across the board because of complex interactions with the PTC calculation. The Congressional Budget Office (CBO) estimated this proposal would reduce coverage by 300,000 people (PDF).
• Impose an income cap on PTC eligibility at 700 percent of FPL (about $110,000 for an individual). CBO estimated that the enhancements increase coverage by 400,000 people (PDF) among those with incomes above 750 percent of FPL, so a cliff at 700 percent would presumably reduce coverage by more than this.
• Codify the recent Marketplace Integrity Rule. The rule would impose new restrictions on Marketplace eligibility and enrollment, but much of it is currently stayed in court. Among other things, it reduces the PTC across the board through an indexing change and requires 2.7 million people to submit additional paperwork. CBO estimated the rule would reduce coverage by 1.8 million people (PDF). 

These estimates add up to about 3.5 million people losing health coverage, and that’s not counting the 2 percent premium contribution floor, which may have the largest effect. The actual effects of these proposals would depend on the specific policies and the timing of passage. But these preliminary figures make clear that it’s not far-fetched that a package including these policies or something like them could reduce coverage relative to current 2026 law without the enhancements.

3. Duration of proposals: Do the new PTC reductions last longer than the enhancements, reducing coverage every year starting in 2028?

The proposal reportedly extends the enhancements for two years (2026 and 2027), but no such time limit is mentioned for the offsetting PTC reductions. If the PTC reductions are permanent, the proposal would substantially reduce coverage in every year after 2027.

4. Deductibles: Does the proposal shift people into plans with higher deductibles without sufficient help for out-of-pocket costs?

The proposal reportedly encourages consumers to shift from silver plans into bronze plans by offering them HSAs in the amount of the premium difference. Bronze plans are the highest-deductible plans available through the Marketplace, with deductibles averaging nearly $7,500 for an individual and potentially twice that for a family. Silver deductibles are generally less than $1,000 (PDF). This difference in deductibles greatly exceeds the difference in premiums for most people. If the proposal pushes consumers into bronze plans without covering the higher cost-sharing, more people will be left with unaffordable out-of-pocket costs.

The Marketplace Integrity Rule also increases the caps on deductibles and out-of-pocket spending for all 160 million people with employer coverage.

5. Preexisting condition protections: Does the proposal expand plans that discriminate against people with preexisting condition?

Reporting indicates that the proposal codifies rules expanding short-term plans and other types of coverage that can charge higher premiums, deny coverage, and exclude benefits for people with preexisting conditions. If so, the proposal would split the overall risk pool, raising premiums for coverage that doesn’t discriminate in these ways while subjecting more people to harmful insurer practices.

6. Other issues: Does the proposal include measures on hot-button issues that could impede a bipartisan deal?

The Affordable Care Act has long prohibited federal funding, including the PTC, from paying for abortions, consistent with long-standing Hyde Amendment rules. States decide whether insurance covers abortion. Some abortion opponents reject this compromise (PDF) and want to prohibit Marketplace plans from covering abortion, even with other funds. Democrats have firmly rejected such changes. Including them in a proposal would greatly reduce the chances of substantial bipartisan support.

Looking forward

Though news of a potential White House proposal to extend the enhancements raises hopes of a possible deal, the details matter. Initial reporting suggests the plan might not address immediate price increases, and several elements would make health care less affordable for American families, raising fears that it could make matters worse overall. As policymakers begin to consider the administration’s plan, the specifics of the proposal warrant careful attention.