Is Tillis the only NC Republican who sees the pain expiring ACA subsidies will bring? | Opinion
Republican lawmakers have never been fans of Obamacare. Still, it’s hard to understand why so few of them have been openly supportive of extending the enhanced Affordable Care Act subsidies set to expire at the end of the year, given the impact it would have on their constituents.
Republicans tend to represent more rural communities, where people are more likely to rely on Affordable Care Act marketplace coverage. They were the most likely to benefit from enhanced subsidies for Affordable Care Act coverage, and they will see their premiums increase the most if those subsidies expire.
According to an analysis from KFF, states won by Donald Trump in 2024 have benefitted the most from the subsidies. Since the subsidies were expanded in 2021, more than half of the national growth in ACA marketplace enrollment has come from Texas, Florida, Georgia, and North Carolina, the analysis found. Around 93% of all enrollees receive tax credits to make their coverage more affordable.
It’s likely why U.S. Sen. Thom Tillis has been one of the only members of his party pushing to extend them. The number of North Carolinians enrolled in ACA Marketplace plans has nearly doubled since 2021, and the vast majority of enrollees got tax credits to help pay for their premiums. Of the roughly 975,000 North Carolinians who enrolled in an ACA Marketplace plan in 2025, about 888,000 of them receive the subsidy and will have to pay more for health coverage if it expires. Some may choose to forego coverage altogether due to the increased expense.
Tillis has been vocal about the need to extend the subsidies since March, urging his colleagues to find a bipartisan solution that extends the tax credits for two years. It’s November now, and the issue lies at the heart of the ongoing government shutdown, which is officially the longest in U.S. history. Democrats have said they will not agree to a plan to reopen the government without an extension of the subsidies, but Republicans have for weeks shown little willingness to negotiate.
Unlike Tillis, however, U.S. Sen. Ted Budd hasn’t pushed to extend the subsidies — he’s done the opposite. In a lengthy thread on X, Budd rejected the idea that the expiration of ACA subsidies would be to blame for health care cost increases next year. He pointed out that only a small fraction of next year’s premium increases are related to the expiring subsidies, and things like “Bidenflation” are much more to blame.
That’s true to some extent, but it neglects the difference between gross and net premium costs. Insurer premiums are only increasing by an average of about 26%, and that’s due to a range of factors, including increases in the cost of health care and prescription drugs. But net premiums — the actual out-of-pocket cost for enrollees — will increase much more sharply. Not only will people incur the annual premium increase, they will also have to start paying the amount of the subsidy they will no longer receive. In North Carolina, the average monthly tax credit is $574.
On average, out-of-pocket premiums are expected to double without the subsidies. The exact increase will depend on a person’s age, location and income level, but it will hit the hardest for older people, and those whose incomes are above 400% of federal poverty guidelines will no longer be eligible at all. In rural parts of the state, the average monthly increase could be close to $800. But for those most affected — a 60-year-old couple making $85,000, for example — that increase could be more than 400%.
Regardless of whether they support the Affordable Care Act, Republicans should understand that allowing health care premiums to suddenly skyrocket is cruel and potentially catastrophic, especially when they lack a plan to make coverage more accessible or affordable. It’s fine to believe that the subsidies are little more than a Band-Aid fix for a deeply flawed system, but ripping that Band-Aid off without an alternative will only make things worse. That’s something that Tillis is reasonable enough to grasp, because he knows it’s bad for North Carolina. It’s a shame other Republicans are willing to ignore it.
Paige Masten is a deputy opinion editor for the Charlotte Observer and McClatchy’s North Carolina Opinion team.
