Enhanced premium tax credits — previously available since 2021 to people receiving health insurance through the Affordable Care Act Marketplace — expired at the end of 2025. But lawmakers are not ready to give up, suggesting ways to restructure how some or all ACA subsidies are delivered to enrollees, including one that would put cash into health savings accounts for people who earn less than 700% of the federal poverty level.
A new survey of more than 60 leading health care policy experts conducted by the Cornell Health Policy Center, however, suggests that the “Health Care Freedom for Patients Act of 2025,”the HSA-based plan introduced by GOP Sens. Mike Crapo and Bill Cassidy, “would have an overall effect of worsening health care affordability for enrollees.”
In fact, 70% of survey respondents don’t support the idea of depositing the value of a household’s enhanced premium tax credit into an HSA instead of applying it directly to their monthly premium.
Several also noted that “requiring enrollees to select a bronze-tier or catastrophic plan to access the HSA contributions” could worsen affordability. But permitting people to use HSA funds to pay for premiums (a practice that is currently prohibited) might mitigate some of the affordability concerns, they added.
Three-quarters of respondents agreed that requiring Marketplace enrollees who otherwise qualify for fully subsidized plans to pay a small monthly premium (as little as $5 or $10) “would measurably reduce Marketplace enrollment among eligible individuals who intended to stay enrolled.” And 37% believed these small premiums would reduce fraudulent enrollment.
What’s more, 80% of respondents said that a scheduled policy change that essentially will end automatic renewals with subsidy for most enrollees — scheduled to take effect in 2028 — will substantially reduce Marketplace enrollment.
“There was strong consensus among health care policy experts that proposed Marketplace policy changes (restructuring enhanced subsidies, requiring the payment of small premiums, and ending automatic renewals with subsidy) could carry meaningful risks for affordability and coverage,” researchers concluded. “A number of respondents referenced a growing literature on the effects of administrative burdens on benefit take-up and retention. As debates over ACA reforms continue, policymakers should be mindful of these possible tradeoffs between administrative requirements and affordability and enrollment.”
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