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GOP faces a familiar dilemma: What to do about Obamacare?

Republican leaders have found themselves in a familiar place: pledging to make major changes to the Affordable Care Act, citing rising health care costs and a looming deadline - but far from agreeing on how to do it.

The White House last week privately floated a framework to extend billions of dollars in ACA subsidies that are set to expire Dec. 31, accompanied by other changes to the health care law long sought by conservatives. But a planned announcement was quickly nixed amid a rebellion from congressional Republicans who balked at the White House’s ideas and process, and it is unclear when - or whether - President Donald Trump will endorse a specific legislative path. Several Senate Republicans have offered their own proposals, though it is not clear whether they can achieve sufficient support to pass the chamber.

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Republicans promised a mid-December vote on how to proceed on the expiring subsidies, in exchange for support from some Democrats for ending the government shutdown in November. Democrats have argued that the simplest and most politically popular option is to extend the subsidies, which were implemented in 2021 and meant to help defray the cost of health coverage during the covid-19 pandemic. But many GOP lawmakers have campaigned for years on pledges to “repeal Obamacare” and say that continuing to fund the subsidies is a nonstarter, calling instead to shift the money to Americans in the form of health-savings accounts.

“The White House has a solution for cost-sharing,” Kevin Hassett, director of the National Economic Council, said Sunday on CBS’s “Face the Nation,” predicting that “people are going to work this out” by Christmas.

“We don’t want to cause panic for the folks who are worried that they’re going to lose the thing that they have,” Hassett added.

The stakes: About 24 million Americans rely on the federal marketplace Healthcare.gov to buy insurance, most of whom now receive the expanded ACA subsidies. The average ACA benchmark monthly premium has already spiked about 26 percent for 2026. An earlier standoff over whether to extend the subsidies fueled the 43-day government shutdown.

Stephen Moore, a longtime conservative economist and informal Trump adviser, said that Republicans are trying to balance several goals: to stave off another potential government shutdown in early February and to address Americans’ rising health care costs. Both parties expect cost of living concerns to be a central issue in next year’s midterm elections.

“People are facing 15- to 20-percent premium increases starting very soon,” Moore said. “You think people have an affordability problem now, wait until those hit.”

The situation also echoes a frequent dynamic in the first Trump administration, where the president and his Republican allies in Congress repeatedly promised - and failed - to pass a plan that would deliver higher-quality, lower-cost health care than the ACA. Those stumbles haunted GOP leaders as they suffered election defeats in 2018 and 2020, and Democrats are preparing to run a similar health care playbook next year.

“People are seeing their health insurance premiums double or triple,” Sen. Amy Klobuchar (D-Minnesota) said Sunday on CNN’s “State of the Union,” vowing to punish Republicans politically if they don’t extend the subsidies. “Either we’re going to pass this by forcing this vote, or we are going to get this on legislation or we are going to march into the midterms and beat them despite their resistance.”

GOP leaders on Capitol Hill are scrambling to put together proposals that could counter the Democrats’ push to extend the ACA subsidies as-is.

Some Republicans in both chambers are pushing for a short-term extension of the subsidies with some tweaks to address conservative concerns about the program, such as adding income caps or additional measures to prevent fraudulent enrollment. Thirteen House Republicans, mostly from liberal-leaning states, sent a letter to House Speaker Mike Johnson (R-Louisiana) during the shutdown warning that a failure to extend a version of the subsidies would “risk real harm to those we represent.”

“We need health care for our constituents, number one, that’s the most important part. Secondly, if we want to be viable in the midterms, I think it’s something we have to think about,” said Rep. Jeff Van Drew (R-New Jersey). “It’s the right thing to do. I don’t want to be the party that takes away people’s health care.”

However, many Republicans oppose extending the subsidies - arguing that they are a pandemic-era relic - and instead see the debate as an opportunity to revisit health care reforms the party has sought in the past. Trump told reporters last week that “some kind of an extension” may be necessary but that he doesn’t want to extend the subsidies if he doesn’t have to.

The Senate health committee scheduled a Wednesday hearing on health care costs. Committee chairman Sen. Bill Cassidy (R-Louisiana) has pushed a narrow plan that would redirect a portion of the subsidies into HSAs that can be used for out-of-pocket costs, not premiums.

“This is not rewriting big portions of the Affordable Care Act,” Cassidy said in an interview last week. “I would argue that it’s a very rifle-shot approach for a specific issue” of addressing health care costs in 2026.

Sen. Rick Scott (R-Florida) has separately proposed allowing the enhanced ACA subsidies to expire but putting the value of the tax credits paid to insurers instead toward HSA-style accounts that people could use for out-of-pocket costs or to pay for premiums for any health insurance plan, not just ACA marketplace plans.

“Any way we can craft this, I think we have to get back to the root cause. And there are probably about 10 things as to why health care is so expensive in the U.S.,” Rep. Greg Murphy (R-North Carolina), a doctor and a member of the House Ways and Means Committee, one of the committees working on a potential health package in the House, told reporters. “I know things move a lot slower in Congress than they do in the operating room, but the time is now, we got to fix this.”

Outside conservative groups, such as the influential Paragon Health Institute, have also urged Republicans to stop funding the subsidies and use the moment to make other long-desired changes to the ACA.

Lawmakers are wrestling with persistent voter concerns over affordability, which conservatives saw as one of the animating issues behind their electoral defeats in Virginia and New Jersey in November.

Early in the month, some figures in the Trump administration were said to be considering a broad health care and spending package that the GOP could attempt to push through Congress on party lines, according to two people familiar with the ideas.

That plan would have combined major changes to health care policy with other GOP goals, potentially including language to formalize the tariffs that Trump has used to define much of his second-term agenda, said the people, who spoke on the condition of anonymity to describe private conversations. Republican lawmakers and conservative political operatives privately say they expect the Supreme Court to strike down Trump’s authority to unilaterally impose the import taxes, requiring Congress to approve the levies if the president wants to keep them in place as they are.

Some lawmakers and administration officials had floated including the $2,000 tariff rebate checks that Trump proposed earlier in November, though the concept has been met with strong opposition from other GOP lawmakers concerned about the national debt.

But the health care plan the administration floated to officials on Capitol Hill last week was far from the party-line proposal that could have unwound much of the ACA - shocking some conservatives who had hoped Trump would at least allow the covid-era subsidies to expire.

“This is the Dems’ disaster. Why they would run toward it, I have no idea,” said one miffed Trump ally, who spoke on the condition of anonymity to share a candid assessment.

“We thought the White House was digging in on this, that Obamacare was a big giveaway to insurance companies,” said another, drawing a connection to Trump’s recent friendly meeting with New York mayor-elect Zohran Mamdani. “Now the White House is on its own doing this, and they’re having conversations with Mamdani.”