As Congress spent months arguing over COVID-19-era enhanced premium tax credits that many people on the Affordable Care Act used to subsidize their health insurance, a relatively narrow debate over a single policy grew into a much broader and more complicated discussion about how to lower health care costs. 

Concerns about those costs are a top issue for voters ahead of this year’s midterms. But whether Congress can meaningfully address the issue and how candidates communicate that idea to voters depends on the type of cost increases and what is driving them. 

A main reason is that health-related costs mean different things to different people, such as higher insurance premiums, more expensive drugs, co-pay increases, surprise charges or unexpected gaps in coverage.

“Health care is probably the most complicated sector of the economy,” said Jonathan Burks, executive vice president of health and economic policy at the Bipartisan Policy Center. “I think when policymakers are talking about affordability, the reason that they can say ‘affordability’ and yet be nowhere near agreement on what they specifically want to do is because of that complexity.”

And voters can miss that nuance, when the messaging from congressional candidates comes largely in the form of a 30-second campaign ad or sound bite.

Polling suggests that health costs are a major priority for voters, though the issue is more salient for Democrats.

According to separate polling from KFF, more than 40 percent of voters said health care costs will have a “major impact” on both their decision to vote in the midterms and which party they would support.

The White House and Congress are positioning themselves ahead of November with messaging on specific plans they claim will lower out-of-pocket costs for Americans.

President Donald Trump’s administration has touted the rollout of the TrumpRx that offers consumers access to purchasing drugs, as well as his attempt to lower drug prices through individual deals with pharma companies.

Trump has called on Congress to pass a suite of health care legislation to lower costs, though he said in an interview Tuesday that he wasn’t planning to make any major legislative push during the rest of his term. 

“In theory we’ve gotten everything passed that we need,” Trump said during an interview with Fox Business.

Contrasting plans

In Congress, Republicans have promoted health savings accounts, so-called cost-sharing reductions for ACA plans and further drug price reforms.

The House New Democrat Coalition on Wednesday unveiled a health care affordability plan that includes extending the expired tax credits and restoring Medicaid dollars that were cut in the 2025 reconciliation law. Last week Senate Democrats rolled out a drug pricing plan that includes expanding Medicare’s drug price negotiation power and examining ways to lower drug prices for people on employer-sponsored insurance.

“One of the top things we’re hearing is affordability and health care from our constituents,” said Rep. Mark Pocan, D-Wis., a regional vice chair for the Democratic Congressional Campaign Committee. “People know that we’re fighting for them, and if nothing else, not only is it going to be a strong election issue, but you know, it’s also making people realize that maybe our health care system needs an overhaul.”

The disparity between the Republican and Democratic plans shows how broad the issue is.

Providing subsidies for individuals who receive insurance through the Affordable Care Act is a different animal from lowering Medicare drug coverage costs or providing health savings accounts for certain ACA marketplace enrollees — neither of which would affect premium prices.

And for the 60 percent of nonelderly adults with employer-sponsored coverage, their health premiums and other out-of-pocket costs are largely based on what their employers negotiated with insurers. The 1974 law known as ERISA sets employer-sponsored health plan standards but is a less talked about issue in Congress.

“It’s an area that probably gets less policy attention than others,” said Burks, pointing to polling that people generally rate employer plans positively. “The last major reforms in that space were done as part of the ACA.”

While the debate over the enhanced premium tax credits couldn’t break beyond partisan divides, Congress has made modest progress on a handful of bipartisan health care issues. 

Lawmakers included a slate of restrictions on pharmacy benefit managers in the fiscal 2026 appropriations law enacted late last month. The law stipulates that for Medicare Part D, the drug benefit for Americans age 65 and older, PBM compensation be based on the market value of the services rather than a drug’s price.

Meanwhile, the House Energy and Commerce Committee has held a series of hearings on health care costs, during which lawmakers from both sides of the aisle have grilled the health care industry over its role in high costs. 

Last month, the CEOs of major health insurers struggled to answer the panel’s questions about what they’re doing to lower the costs of care. The committee on Wednesday heard from industry executives and lobbyist groups and pressed them on market consolidation and other issues.

‘A natural political death’

Despite repeated efforts, Congress was unable to extend the now-expired enhanced ACA tax credits — gaining nothing from the record 43-day shutdown despite a majority of Congress supporting an extension.

Grant Reeher, a political science professor at Syracuse University, said part of the problem with the enhanced subsidies is that they raise health care spending but lack a mechanism to control costs. They also affect a relatively small subset of the population, many of whom had “some pretty high salaries or at least some pretty decent assets in the bank,” he said. 

All of that made an extension a tough sell for Democrats.

The Congressional Budget Office in September estimated that a permanent extension of the tax credits would’ve increased the federal deficit by $350 billion by 2035. 

Reeher said the issue likely won’t be revisited in a substantial way until Democrats control both chambers and the White House. He said in the interim, the issue has “died a natural political death.”

One longtime Democratic consultant, who wanted to remain anonymous to speak candidly, said the fizzled effort to renew the credits wasn’t a political failure for the party as it elevated the public’s understanding of the ACA for a certain population and cemented tackling health affordability as a key voter issue.

The effects may be materializing for researchers.

Bailey Flynn, a postdoctoral research associate at Cornell University’s Jeb E. Brooks School of Public Policy who researches hardships in accessing the health system, saw a shift in how people perceive costs last year.

It went from a more abstract issue in January 2025 to a more pressing concern by December, becoming “more real” when the tax credits were expected to expire, she said.

That may be the case even as some individuals might not see those premium spikes this year. At least six states are subsidizing some of the gap from the expired premium tax credit for 2026, meaning individuals in California, Colorado, Connecticut, Maryland, Massachusetts and New Mexico may not be as affected.

While her research does not focus on actual election turnout, the surveys assess a person’s intention to engage on health care issues in some way, such as planning to vote, attend a community meeting or sign a petition.

With the credits expiring and other health care costs rising, the number of people with personal experience of this issue increases.

“I think there’s a question of, are we going to have in midterms just a vastly increased pool of people who have had firsthand experience in the last 12 months with really high costs of care or not being able to afford things?” she said. “And is that going to shape their actions around the elections?”