Analysis-Clash over healthcare subsidies threatens to reshape 2026 midterms

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By Nathan Layne

BECKLEY, West Virginia (Reuters) -For Larry Jackson, a Donald Trump-backing Republican hoping to unseat his party’s incumbent in a West Virginia congressional primary next year, the fight in the U.S. Congress over Affordable Care Act subsidies is both personal and political ammunition.

Jackson, 42, says steep ACA premium hikes facing West Virginians — estimated by one think tank to average nearly 400% per enrollee next year — highlight the stakes of the expiring subsidies. It’s an issue he plans to spotlight in a broader cost-of-living message for his campaign to unseat Representative Carol Miller, who has not committed to keeping them in place.

The elevation of ACA subsidies as an electoral issue among Republicans in one of the nation’s most reliably conservative states a year before Americans go to the polls for midterm congressional elections underscores the issue’s potential potency.

Jackson, a business owner, has relied on the ACA to provide health insurance for his family of eight. Without the enhanced subsidies, due to expire at the end of December, his monthly premium is set to quadruple to $1,850 a month.

Democrats’ refusal to approve discretionary funding for federal agencies until Republicans agreed to extend the subsidies triggered the longest government shutdown in U.S. history. It ended on Wednesday without a deal to extend them.

Democrats are expected to campaign vigorously on the hikes as they seek to break the Republican grip on Congress in next November’s elections.

“These tax credits cannot expire. It’s going to hurt a lot of people in West Virginia,” Jackson told Reuters. “We can all agree there are problems with the Affordable Care Act, but the government needs to extend these credits as they work that out.”

The subsidies, introduced during the COVID-19 pandemic, expanded federal assistance for Americans seeking health insurance through marketplaces created by the ACA, also known as Obamacare.

With an aging, rural population and some of the nation’s highest rates of poverty and chronic illness, the state of nearly 2 million people faces among the biggest proposed premium increases in the country. The subsidies have provided a crucial lifeline to tens of thousands of West Virginians previously priced out of Obamacare coverage.

A deal struck on Sunday between Republicans and a handful of Democrats in the Senate to end the 43-day shutdown left the fate of the subsidies in limbo. While Senate leadership promised a vote on the subsidies in December, Republican leaders in the House of Representatives have not committed to a vote on them.

SUPPORT FOR SUBSIDIES

Of the more than 30 people Reuters spoke to in West Virginia, a comfortable majority, including all Democrats and several Republicans, supported extending the subsidies until Congress could formulate a plan to make health insurance more affordable.

Republicans who opposed the extension expressed concerns about fiscal discipline or potential fraud in the program, including one whose business was insuring its employees through Obamacare.

Keeping the subsidies would likely receive broad support nationwide, according to a poll conducted by health policy organization KFF from October 27 through November 2. It found three-quarters of U.S. adults backed their extension.

Simon Haeder, an associate professor of public health at Ohio State University, said the issue is unlikely to move the needle enough in the midterms in a staunchly Republican state like West Virginia, where Trump won 70% of the vote in the 2024 presidential election. But it could make a difference in so-called purple states closely divided between the two parties.

“It’s going to give Democrats something to run on,” said Haeder, who has researched the intersection of health policy and politics. “If you’re a Republican in a purple state, you’re going to have to answer for people losing healthcare.”

REPUBLICANS SEEN AS LESS EFFECTIVE ON HEALTHCARE

In an October Reuters/Ipsos poll, 37% of Americans said Democrats had a better approach to healthcare, compared with 27% who favored Republicans.

Brian Darling, a Republican strategist and former Senate aide, said inflation and the broader economy will likely be top of mind for voters next November, but healthcare policy could tip close races.

“Republicans need to have a health reform proposal drafted and ready to deploy in the enhanced subsidy debate or they will lose on policy and at the ballot box,” he said.

The Center for American Progress, a liberal think tank, estimates ACA enrollees in West Virginia face an average 387% increase in their premiums without the subsidies, more than any other state.

According to KFF projections, a 60-year-old couple making $85,000 in the state’s first congressional district – represented by Miller – will see premiums jump by 654%, or $602, to $4,540, second only to Wyoming’s lone district at 693%.

Tami White, who works at an insurance agency in West Virginia, said her firm has been renewing lower-income clients in new ACA plans, with premium hikes ranging from 20% to 100% for similar or downgraded plans. It has yet to renew any clients with earnings above 400% of the poverty line due to the cost.

While households below the 400% threshold – $84,600 for a couple – will still qualify for a lesser tax credit, those above it will receive nothing if the subsidies expire.

As many as 15,000 West Virginians are at risk of losing health coverage because they cannot afford the new premiums, according to the West Virginia Center on Budget & Policy, a progressive policy research group, potentially compounding the state’s healthcare problems ahead of planned Trump administration cuts to Medicaid, the government health insurance program for low-income Americans.

The reductions are part of the sweeping package of tax and spending cuts Trump signed into law in July. Once those cuts are fully implemented, the state’s hospitals, which rely heavily on Medicaid dollars, could lose $1 billion per year, according to West Virginia Hospital Association CEO Jim Kaufman.

Miller, who is facing the primary challenge from Jackson and two other Republicans, did not respond directly to questions on whether she supported extending the tax credits. Republicans could negotiate on the credits once the government reopens, Nicolas Gray, a spokesman for Miller, said in a statement.

The issue has hit home for Jackson’s campaign manager as well. Patrick Krason said he blamed both parties for his new premiums, projected to rise five times to $2,200 a month.

“I am mad at everybody, at the legislative branch, Republicans and Democrats,” he said.

“Greedily for myself, I would like (the subsidies) extended for a year,” he said. “And, you know, maybe they decide they can actually come up with a plan.”

(Reporting by Nathan Layne; editing by Ross Colvin and Bill Berkrot)