Millions of Americans risk losing subsidies next year that help them pay for health insurance following President-elect Donald Trump’s election win and Republicans’ victory in the Senate.

The subsidies — which expire at the end of 2025 — came out of the 2021 American Rescue Plan, and increased the amount of assistance available to people who want to buy health insurance through the Affordable Care Act. The American Rescue Plan also broadened the number of people eligible for subsidies, extending them to many in the middle class.  

The looming expiration date means that the incoming Congress and next president will need to decide whether to extend them — something Trump and Republicans have already signaled they don’t support, said Chris Meekins, a health policy research analyst at the investment firm Raymond James.

“If Republicans end up winning the House, in addition to the Senate and White House, having a GOP sweep, I think the odds are less than 5% they get extended,” said Meekins, who was a senior HHS official in Trump’s first term. Even Democratic control of the House likely won’t save the subsidies, he added. 

Several important House races have still yet to be decided. As of Thursday afternoon, House Republicans had won 209 seats, just nine short of the majority, according to an NBC News tracker. 

In 2024, more than 20 million people got health insurance through the ACA, according to the Centers for Medicare and Medicaid Services. 

Since the 2021 subsidies went into effect, enrollment in ACA plans with reduced payments doubled, particularly in Southern red states, said Cynthia Cox, the director of the program on the ACA at KFF, a nonpartisan health care policy research group. 

The Inflation Reduction Act, passed in 2022, extended the subsidies through 2025. In 32 states where data is available, 15.5 million people receive the subsidies, according to KFF.

If the subsidies aren’t extended, the Congressional Budget Office — a nonpartisan agency that provides budget and economic information to Congress — estimates that nearly 4 million people will lose their coverage in 2026 because they won’t be able to afford it.  Enrollment will continue to fall each year, with coverage reaching as low as 15.4 million people in 2030.  

A spokesperson for Trump did not respond to a request for comment.

It’s possible, Cox said, that the current Congress could extend the subsidies during the so-called lame-duck session, though she added that’s unlikely.

“The election results make it much less likely,” Cox said. “And what we’re looking at is significant increases in what people pay for their premiums. It’s going to average more than 75% increase. For some people, it will be more than double.”

The subsidies are a hard pitch to Republicans, Meekins said, because they’re expensive. The CBO estimates that it would cost $335 billion over 10 years to permanently extend them. 

What’s more, Trump and Republicans in Congress have already said they would make “massive” changes to the health care law.  

Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University, said if Republicans do take full control of Congress, those changes could be significant.

“President Trump will likely cut funding for outreach for ACA plans,” Gostin said. “This means fewer people will know their rights under the law and many will not sign up for ACA health care plans. Trump is also likely to cut Medicaid funding and support states that refuse to expand Medicaid coverage.”

Gostin also noted that “challenges to the ACA’s preventive services mandate are under way in the courts.” The mandate requires that health insurers fully cover certain preventive services, including cancer screenings like colonoscopies and mammograms, at no cost to the patient.  

In June, a federal appeals court said the mandate must stay in place until the case is ultimately decided.  

Cox said she expects Republicans to keep dismantling the ACA, similar to Trump’s first term, when they eliminated the tax penalty linked to the law’s individual mandate, which required people to have health insurance or pay a tax. The mandate is technically still in place, but the penalty was reduced to zero.

“If Republicans control the House, the Senate and the presidency, then we might see a repeat of 2017,” she said. 

Gostin said eliminating the ACA entirely will be a challenge, even if Republicans control all three chambers.

“The ACA will survive, but only a bare-bones version,” Gostin said.