The future of Obamacare hangs on a few seats in Congress. Here's what could happen next

"Repeal and replace" has long been the Republican mantra when it comes to the Affordable Care Act.

These days, not so much.

"I'm not running to terminate the ACA," former President Donald Trump wrote in a Truth Social post in March. During the Sept. 10 presidential debate, Trump again said he did not plan to eliminate the program. That is, unless he could "come up with a plan that's going to cost our people, our population, less money and be better health care than Obamacare."

It's a remarkable about-face coming from a candidate who said in Oct. 2016 that real change, "begins with immediately repealing and replacing the disaster known as Obamacare."

It also shows how entrenched former President Barack Obama's signature health-care legislation has become in American life. Around 60% of Americans hold a favorable opinion of the 2010 health care law, a recent KFF poll found. A record number of people — over 20 million — signed up for coverage on the ACA marketplace in 2024.

But even as existential threats to the program appear to recede, Republicans and Democrats are still deeply divided over what the health care law's role should be in the future, said Cynthia Cox, vice president and director of the program on the ACA at KFF.

"When you're asking about ways to improve the ACA, there's a lot of different interpretations of what that might mean," Cox said. "One person's improvement might be another person's weakening."

Depending on who takes the White House, and which parties win majorities in the House and Senate in November, here's what could be in store for Obamacare.

If Democrats manage to hold their narrow majority in the Senate, or flip the GOP-controlled House, they'll likely make extending the ACA's enhanced subsidies a top priority, Cox said. The government-backed aid, originally passed during the pandemic under the American Rescue Plan in 2021, and then prolonged in The Inflation Reduction Act in 2022, is set to expire at the end of 2025.

For her part, Harris has made clear she wants to keep in place the boosted financial assistance, which has significantly lowered the costs of coverage for people buying plans on the ACA marketplace. An individual earning $60,000 a year now has a monthly premium of $425, compared to $539 before the enhanced subsidies, according to a rough estimate provided by Cox. Meanwhile, a family of four making about $120,000 currently pays $850 a month instead of $1,649.

 "Whoever wins the elections, it's not clear whether these subsidies would be renewed or not," Cox said.

Joseph Costello, a spokesperson for the Harris campaign, reiterated that the vice president wants to see the enhanced subsidies stay in place.

"Vice President Harris is fighting to improve health care and lower costs, and part of her plan includes making permanent credits that are lowering health care premiums by an average of about $800 a year for millions of Americans," Costello said.

The Harris campaign released a report on Monday that paints a dire picture of health care under a hypothetical Trump administration. The campaign based the report on the conservative governing blueprint Project 2025, which Trump has disavowed, and on a full repeal of the ACA, which Trump has backed away from somewhat. Still, the report warned that under the most hardline policies, around 500 rural hospitals could close and millions of Americans could lose their health insurance.

The Trump campaign did not reply to a request for comment.

If Democrats prove successful in maintaining the enhanced subsidies, they may then turn their attention to delivering even deeper relief to marketplace policy holders, Cox said. Deductibles, in particular, remain high. The average ACA plan deductible, or amount a person must spend before their coverage kicks in, was over $3,000 in 2024, with some plan deductibles exceeding $7,000, KFF found.

"That might be where you see additional interest for Democrats: To increase subsidies for cost-sharing assistance to lower deductibles," Cox said.

The remaining 10 states that have so far refused to adopt the ACA's Medicaid expansion are likely to be another focus point for Democrats, experts say.

Under Obamacare, the federal government provides nearly all of the funding for states to widen their eligibility pool for the free health insurance. But in 2012, the Supreme Court ruled that Congress had exceeded its constitutional power by requiring states to expand Medicaid — one of the main ways the law aimed to increase coverage rates.

But Democratic lawmakers could encourage the hold out states, which include Texas, Wyoming and Florida, to expand their Medicaid coverage by closing the gap in federal funding, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University's McCourt School of Public Policy. Currently, the federal government covers 90% of the state's expansion costs.

"Persuading the 10 states would help millions of people to afford needed medical care," said Mark Duggan, The Wayne and Jodi Cooperman Professor of Economics at Stanford University.

Republicans and Trump also tend to complain about the ACA being too expensive. But they're focused on the taxpayer tab, Cox said.

"This is often the debate," she said. "Who should be spending the money: The federal government, or the people who are sicker or uninsured?"

The easiest way to reduce the cost of the program would be to let the enhanced subsidies expire, she said, adding that "that's likely to happen if Republicans hold on to either the House or Senate."

Permanently extending the enhanced subsidies could cost around $25 billion a year, according to an estimate by the Congressional Budget Office.

"That's the concern from Republicans about extending them," Cox said.

Around 3.8 million people will lose their health insurance if the aid is dropped, the Congressional Budget Office estimates. Those who maintain their coverage are likely to pay higher premiums.

The ACA's expanded Medicaid coverage would probably be another area GOP lawmakers and Trump target for cost cutting measures, experts say.

Recent GOP proposals call for reducing the federal government's funding to states for Medicaid, said Robin Rudowitz, a vice president at KFF and the director of its Program on Medicaid and the Uninsured. These plans could lead to cutting the federal funding match rate on extended Medicaid coverage to 50% from 90%.

"This would be a large cost shift, so states may face hard decisions to restrict coverage, leaving many people in the expansion group without affordable coverage options and likely uninsured," Rudowitz said.

The previous Trump administration also increased the availability of non-ACA compliant health insurance options, including short-term plans, experts say. Big Republican gains in November would likely lead to a repeat of that.

Proponents of these plans say they allow insurers to offer consumers lower monthly premiums because they're not required to cover as many services, Cox said. At the same time, the plans are able to reject people with pre-existing conditions or charge them more. While Trump was in office, enrollment in short-term plans spiked.

This is a troubling dynamic for proponents of the ACA, Corlette said. That's because these plans "siphon away" younger and healthier people from the marketplace, Corlette said.

"The risk is that you're going to be left with the ACA plans only serving sick people, and that's not a sustainable insurance market," she said. "Over time, ACA premiums will go up and up and up."

Republican vice presidential nominee Sen. JD Vance recently hinted at a health care system just like the one Corlette expressed concern about.

"We're going to actually implement some regulatory reform in the health care system that allows people to choose a health care plan that works for them," Vance said at a September campaign rally in Raleigh, N.C.

The Ohio senator said that they'd "allow people with similar health situations to be in the same risk pools."