For a critical sliver of the Republican majority, the impending expiration of what are called enhanced premium tax credits after Dec. 31 is a pressing concern as they potentially face headwinds in a 2026 midterm election that will be critical to President Donald Trump’s agenda.

One of those is first-term U.S. Rep. Ryan Mackenzie, R-Pa., whose victory for the Allentown-area seat last year was among the narrowest in the nation.

Mackenzie is part of a bipartisan group that has been pressing for an eleventh-hour compromise, advocating for an extension of the tax credits that tries to fix perceived flaws and bring down health care costs. But the push is a long shot due to entrenched GOP opposition to the health overhaul known as “Obamacare.”

“I think that we need to deal with the reality of where we are now and even if you have a broken system, that doesn’t mean that you shouldn’t provide or offer relief to individuals who are dealing with those high costs right now,” Mackenzie said in an interview with The Associated Press.

Democrats have been laying the groundwork, starting with this fall’s shutdown fight, to make the health care issue a focus of next year’s campaigns.

The party’s strategy for capturing the House majority centers on pinning higher bills for groceries, health insurance and utilities on the policies of Trump and Republicans.

Republicans torn over an extension

In Washington, Republicans from competitive House districts have authored or signed onto bills that would temporarily extend the tax credits. A new bipartisan proposal unveiled Thursday has drawn support from roughly 15 Republicans and 20 Democrats so far.

“I have 40,000 people in my district who rely on this health care and doing nothing to prevent a spike in their premiums is wrong,” said U.S. Rep. Jen Kiggans, R-Va., a sponsor of the plan.

Thirteen Republicans — including Mackenzie — signed a letter in late October to the House speaker, Rep. Mike Johnson, R-La., encouraging the temporary extension of the tax credits, saying letting them “lapse without a clear path forward would risk real harm to those we represent.”

Johnson hasn’t committed to a short-term extension vote before Jan. 1 and has dismissed the looming premium increases as affecting a small percentage of Americans.

More than 24 million people have ACA health insurance, including farmers, business owners and other self-employed people who don’t have other health insurance options through their work.

Many benefit from subsidies that lower their out-of-pocket cost. Those subsidies include the enhanced premium tax credits, which were added and then extended under Democratic President Joe Biden when his party was the majority in Congress.

Some Republicans — including Mackenzie — couch their support for an extension with the caveat that changes must be made. One is rooting out insurance broker fraud. Another is backing off subsidies for higher earners.

Time is running out

U.S. Rep. Kevin Kiley, one of the California Republicans whose districts have been redrawn to favor a Democrat, sponsored a bill to extend the tax credits for two years. His bill would also impose an income eligibility cap to exclude higher earners.

Kiley said the current system isn’t working, but there’s not enough time to make systematic reforms before millions of Americans “just suddenly pay double on their premiums.”

U.S. Rep. Jeff Van Drew, R-N.J., also has a bill to temporarily extend the credit, and said letting the subsidy lapse will make it harder for Republicans to retain the majority next year.

“People say, ‘well, it’s not that many people,’” Van Drew said. “The kind of election we’re going to have in the midterms in multiple districts is going to be decided by one or two points. It’s going to be close. It’s going to be tight, and it does matter. It absolutely matters politically.”

U.S. Rep. Richard Hudson of North Carolina, chair of the House Republicans’ campaign arm, said the tax credits won’t be “decisive” in next year’s election when other things are likely to be on voters’ minds.

Democrats will run on affordability

But U.S. Rep. Suzan DelBene of Washington state, who chairs the House Democrats’ campaign arm, said swing-district Republicans won’t be able to distance themselves from the expiration of the tax credits.

“The number one issue across the country is affordability and health care is a key part of that,” DelBene said.

The Congressional Budget Office projects that 3.8 million more people will be uninsured in 2035 if the tax credits aren’t extended. But the tax credits also come with a cost: Extending them would increase the deficit by $350 billion over the next decade.

The expiration of the tax credits means enrollees will see annual premiums more than double — from an average of $888 in 2025 to $1,904 in 2026, according to health care research nonprofit KFF. That’s an increase of 114%.

The size of the increases varies by state, age and income and will be more extreme in Mackenzie’s district, according to state data, which puts the average premium increase at 178%.

A primary field of Democrats is shaping up for the nomination to challenge Mackenzie. They say they’re hearing from people who are struggling to afford rising premiums.

One of those Democrats, Ryan Crosswell, said rising insurance costs are a “breaking of promises” by Trump, Republicans and Mackenzie. Another Democrat, Carol Obando-Derstine, called the impending expiration a “crisis of (Mackenzie’s) own making.”

Mackenzie says he’s made it clear repeatedly that he supports an extension, but that “I am not the speaker, I don’t set the calendar or the agenda. I’m not the leader, I can’t call up bills.”

Enrollees facing hard choices

In Mackenzie’s district, more than 20,000 people received the enhanced tax credits in 2025, according to state data. He won his race last year by 1 percentage point, or about 4,000 votes.

One of those 20,000 people in Mackenzie’s district is Patrick Visconti, who switched to a low-premium, high-deductible plan because he couldn’t afford to keep his plan with a premium that is more than doubling from under $200 to over $500 a month.

Visconti, 59, who works as a self-employed landscaper and a bus driver, said the plan he picked is “crappy coverage.”

“I’d rather pay the $200 a month. But I can’t get anything for $200,” Visconti said.

Lynn Weidner, a home care worker in Mackenzie’s district who works nearly 80 hours a week, said her $400 premium will increase to $680. But, she said, she’s leaning toward selecting the plan because she has various conditions — including an iron deficiency — that require regular medical care.

“So I’m trying to find places where I can cut money so that I can afford my insurance come January, which is stressful,” Weidner said.