The 2025 legislative year opened with the arrival of one of the most expansive federal packages in recent memory: Congressional bill HR1 - the legislation formally known as the One Big Beautiful Bill Act; a title which the Democrats managed to get formally dropped in a masterstroke of meaningless political gestures, particularly as everyone still calls it that. The weird name and process aside, the bill will have massive impacts on many aspects of American life for decades and Democrats have made it front and center of their campaign to convince the country the Republicans can't be trusted with the economy and subsequently win back the House, the Senate and the presidency.
Although the healthcare provisions inside it attracted the most public attention and we will be focusing on those, the bill was far broader, a sweeping reorganization of federal taxation, spending priorities, and programmatic structures. It altered Medicaid financing, revised revenue models, adjusted appropriations across multiple agencies, and introduced new compliance and reporting obligations. Healthcare, though central to the national conversation, was only one component of a much larger federal re-calibration.
Its implications for healthcare affordability remain sharply contested. Many argue that the OBBB’s cuts to federal Medicaid support—estimated at over a trillion dollars across a decade—combined with the scheduled expiration of enhanced ACA premium tax credits, will likely drive household costs upward in 2026. Their projections suggest that a typical middle-income family of four, with an annual income around $85,000, could face nearly two hundred dollars more in monthly premiums and almost a thousand dollars more in direct medical costs if confronted with a serious illness. The argument hinges on the idea that reduced federal support creates uncertainty for insurers, prompting higher premiums or narrower networks as carriers hedge against financial risk.
Republican supporters of the bill see the issue differently. They view the OBBB’s trims to federal spending as a necessary correction that restores long-term fiscal discipline. Under their interpretation, the bill’s temporary structure—particularly the non-extension of enhanced subsidies—is intentional. By allowing subsidy enhancements to lapse and encouraging states to take a more active regulatory role, the federal government can limit long-term commitments while allowing competitive forces to exert downward pressure on premiums. In this view, affordability is best achieved not by increasing federal interventions but by giving consumers more flexibility, encouraging provider competition, and reducing regulatory burdens that affect insurer pricing.
This unresolved tension was thrown into sharper relief during the government shutdown. Democrats attempted to pair a budget extension with a renewal of the enhanced ACA subsidies, believing that stabilizing premiums early in the rate-setting cycle would prevent volatility. When the Democrats bravely snatched defeat from the jaws of victory and caved on the shutdown, states were left with a real question: how to protect their residents if federal supports fall away in 2026. It is in this context that we turn to the year’s legislative activity to ask a straightforward but consequential question:
What bills—federal or state—are actually designed to keep healthcare affordable?
Colorado’s HB1006: A State Builds Its Own Safety Net
Colorado answered most decisively. The state’s special-session measure, HB1006, is the most comprehensive affordability bill introduced anywhere in the country this year. The law reconfigures the Colorado Health Insurance Affordability Enterprise and creates a clear trigger mechanism: if Congress does not extend the enhanced premium tax credits for the 2026 plan year, Colorado will activate a state-funded support structure. Under HB1006, up to one hundred million dollars can be directed into the reinsurance program and into subsidies that directly lower premiums for individuals who purchase plans on the exchange. The statute defines “enhanced premium tax credit” by reference to the American Rescue Plan Act and the Inflation Reduction Act, establishes a mechanism for the sale of tax credits to ensure revenue stability, and mandates detailed annual reporting and multilingual community engagement. With an entirely Democratic sponsor roster and the Governor’s signature secured in late August, the bill stands as a parallel affordability framework designed to intervene precisely when federal support lapses.
In practical terms, Colorado chose not to wait on Washington.
But what has Washington been doing?
The stakeholder page shows a field divided not by lack of activity but by philosophical distance. Several high-profile Democratic bills form the backbone of federal affordability efforts this year. HR247, the Health Care Affordability Act, proposes stabilizing premiums by renewing federal support mechanisms and adjusting the structure of marketplace subsidies. Its approach is straightforward: affordability is achieved by lowering the financial burden on consumers through targeted federal investment.
A parallel Democratic effort appears in HR3947, the Easy Enrollment in Health Care Act. This bill attempts to integrate tax-filing data with marketplace enrollment triggers, widening the insured pool by making enrollment almost automatic for uninsured individuals. Democratic lawmakers argue that such administrative alignment will reduce uncompensated care, which in turn stabilizes premiums. Another major Democratic proposal, HR4849, combines subsidy stability with specific cost-containment pressures aimed at insurer practices and provider pricing. All three measures interpret affordability as something achieved through subsidy continuity and structural regulation.
Republican bills take a different approach. HR3080, the Health Care Fairness for All Act, is emblematic of a market-driven philosophy. The bill expands access to alternative insurance products, increases the flexibility of health-savings accounts, and relaxes certain ACA-era restrictions so that insurers can offer lower-cost, narrower forms of coverage. The guiding logic is that premiums fall not because the federal government offsets them, but because consumers have wider choice and insurers face fewer compliance-driven costs. Another notable Republican effort, HR____ (from the dataset), focuses on widening access to short-term plans and removing specific regulatory requirements that supporters argue inflate premiums unnecessarily.
There are faint signs of bipartisan engagement, most visibly in HR5145, the Bipartisan Premium Tax Credit Extension Act. While its scope is modest, the bill recognizes that sudden subsidy cliffs destabilize both households and insurance markets. It proposes a limited extension of premium tax credits without embracing the broader subsidy structure preferred by Democrats. Despite its narrower design, the bill illustrates the rare points where both parties acknowledge the connection between predictable federal policy and premium stability.
Congressional activity in 2025 thus reflects two competing frameworks. Democrats treat affordability as a public guarantee requiring federal underpinning and administrative streamlining. Republicans argue that affordability is the natural result of market competition and regulatory restraint. What is wearily predictable however is that none of these bills have been enacted. In fact, none have even made it out of committee.
So, if Americans are to get any relief from healthcare costs it will have to come from the states.
State Legislation in 2025: Small Tools, Big Stakes
Outside Colorado, the state-level bills introduced in 2025 form a narrower set of affordability strategies than the scale of the federal debate might suggest. While none approach the scope of CO HB1006, several states explored smaller levers intended to influence costs, either through adjustments to insurance-premium tax policy or through targeted tax credits designed to support employers or individuals buying coverage.
Click a state to see the bills, and click detail to read a bill.
A number of states focused on premium-tax structures. Arkansas’ HB1665 proposed eliminating a long-standing credit insurers use to offset insurance-premium tax liabilities. Supporters framed it as a cleanup measure; critics argued it risked upward pressure on premiums. The bill died, but it reflects the recurring tension between revenue simplification and affordability. Oklahoma’s SB1135, meanwhile, clarified and modernized the premium-tax base, carving out specific exemptions and attempting to prevent double taxation on certain products. It passed with Republican backing, showing that some states are adjusting insurance-tax structures even if they are not creating new affordability programs.
A second cluster of bills uses the tax code to nudge affordability from the consumer side. Connecticut’s SB116 and Massachusetts’ H3025 both aim to make long-term care insurance more affordable through tax credits, reflecting concern over rising premium rates in that market. Minnesota’s HF2071, SF722, and SF2352 each explore adjustments to the state’s insurance-premium tax or deductions related to health-insurance premiums, although all remain in committee. New Jersey’s A4007 and A5604, along with Ohio’s HB133 and SB129, pursue a similar strategy from the employer angle, offering credits to small businesses that contribute to workers’ coverage.
New Mexico’s HB2 is one of the few enacted measures beyond Colorado this year, updating elements of the state’s coverage framework and adjusting funding streams in ways expected to influence affordability indirectly. Georgia’s SB192 also deserves mention for attempting a broader package of consumer-protection and affordability provisions within the marketplace, though its progress remains limited.
Taken together, these bills show states experimenting with modest affordability tools—tweaks to premium-tax regimes, targeted consumer credits and incentives for small employers—rather than building the kind of structural fallback system Colorado enacted. The political divide is visible but not absolute: Democrats often gravitate toward credits and supports, while Republicans tend toward premium-tax restructuring. Most proposals remain in committee, and only a handful have been enacted, leaving the majority of states without meaningful protection if federal subsidies lapse in 2026.
Looking Ahead to 2026: A Year Shaped by Premium Notices
As 2025 closes, affordability remains a defining political issue. Whether premiums remain stable or rise sharply in 2026 depends primarily on two factors: whether Congress renews the enhanced premium tax credits, and whether states have prepared their own affordability safeguards. If Congress extends the credits, Democrats may claim vindication, arguing that the OBBB’s temporary supports were only one piece of a longer-term affordability arc. If Congress does not act, premiums may rise, particularly in states without the protective layers seen in Colorado, Massachusetts and Vermont. In such a scenario, Republicans will argue that federal overreach and structural distortions created the conditions for price increases, while Democrats will argue that Republicans prevented the very extensions needed to prevent them.
Voters, meanwhile, will judge the matter through their premium notices. Healthcare affordability is set to shape both the 2026 midterms and the next presidential election. And with states increasingly moving on their own, the federal-state relationship in healthcare may be entering a period of unusually rapid evolution.
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