Democrats emerged from the longest government shutdown in U.S. history with a hard-won promise from Republicans: The Senate will vote next month on legislation to extend Affordable Care Act subsidies that Democrats desperately want to preserve before they expire at the end of the year.
But Democrats will need Republican votes to pass a bill — and a deep divide between the two parties over abortion is already threatening to scuttle any deal.
Republicans, under pressure from antiabortion advocates, have insisted that any extension should include additional restrictions on abortion coverage for plans that get government subsidies. That request is dead on arrival with Democrats.
“That’s the message that we’ve shared with a lot of our Democrat colleagues: You can’t do it under your existing framework, and you’re never going to get any Republican votes because we believe strongly taxpayer dollars should not go to fund abortions,” Sen. Mike Rounds (R-South Dakota) said. “It’s pretty clear Republicans are solid on that particular issue.”
Democrats argue the subsidies already contain abortion restrictions and that Republicans are picking a fight that will doom the nascent negotiations.
“To think that they would use this as the demand, which they know is not ever going to get Democratic support — what it tells me is that they’re not serious about extending these tax credits, and they’re not actually trying to find a path forward,” said Sen. Tina Smith (D-Minnesota).
For months, Democrats have been pushing Republicans to extend premium subsidies that Congress put in place under President Joe Biden in 2021 to support most of the 24 million Americans enrolled in ACA insurance plans . Without an agreement, more than 20 million people who benefit from the subsidies will face higher health insurance premiums, and millions are expected to become uninsured.
Democrats said they wouldn’t vote to fund the government unless the subsidies were extended. But Republicans refused to negotiate on policy changes until the shutdown ended. That happened last week when a cohort of Senate Democrats accepted the promise of a future vote on a bill of their choice on the subsidies.
Now Democrats have less than a month to negotiate a bill that can win the support of at least 13 Republicans in the Senate. ACA monthly premiums for 2026 have already spiked 26 percent as the expiration date nears.
But Republicans are insisting that the subsidies should not be allowed to be used on any plan that covers abortion — regardless of whether the subsidy itself pays for the abortion coverage.
That’s only one of several potential changes to the subsidies that Republicans are seeking. They have also suggested implementing minimum out-of-pocket premiums and income caps, or turning the subsidies into a direct payment that could be used for health care costs. However, the abortion provision appears to be the proposal with the least room for compromise with Democrats.
Currently, in states that haven’t banned abortion, insurance plans purchased using the subsidies can offer abortion coverage, but the federal government can’t pay for it. Instead, enrollees are asked to pay at least $1 per month to pay for the coverage themselves to ensure that federal money doesn’t directly pay for abortions.
That monthly surcharge has historically exceeded the cost of abortions that insurance plans pay for, according to the Government Accountability Office.
So Democrats argue that the subsidies already comply with the Hyde Amendment, a long-standing law that bans the use of federal funds for abortions.
But antiabortion advocates and many Republicans argue that the current policy is insufficient because the subsidies help Americans buy plans that cover abortion, even though the surcharge means the federal government is not paying for it directly.
Susan B. Anthony Pro-Life America — an influential antiabortion organization that maintains a public scorecard of lawmakers’ votes on abortion-related legislation — sent a letter to senators earlier this month saying any votes to extend the existing ACA premium subsidies without changes would be double-weighted in its rankings.
The $1 surcharge for abortion coverage emerged through a compromise between antiabortion Democrats and President Barack Obama to pass the ACA in 2010, which was paired with an executive order assuring no federal funds would be used to subsidize abortion. Abortion rights opponents had originally pushed for a provision in the ACA that is close to what Republicans are now demanding.
Antiabortion groups have long argued that the ACA does not adhere to the Hyde Amendment because of that deal.
“The surcharge is a joke. It still has the effect of subsidizing abortion plans with taxpayer funds,” said Marjorie Dannenfelser, president of Susan B. Anthony Pro-Life America. “It’s really wishful thinking to think it is not an issue.”
Dannenfelser said she has spoken to every Republican senator she could about her organization’s position and had gotten little pushback. She expects Republicans to refuse to vote for any bill to extend the subsidies that doesn’t include the restrictions that her group is seeking — which could make it impossible to reach a bipartisan agreement.
“It’s obviously going to be very tough. Gaining enough Democrats to make that happen would be pretty record-setting. It would be a miracle,” she said. “But it depends on how much they care about actual affordable health care.”
Democrats say they won’t agree to include the abortion language Republicans are seeking in the bill they draft. They argue it would severely restrict Americans’ access to abortion because insurance companies would likely drop abortion coverage altogether to remain eligible for the ACA marketplace.
They also say it would complicate coverage in states that require insurance plans cover abortion. Each state has its own laws governing whether abortion can be covered through the ACA marketplace. Twenty-five states bar all marketplace plans from covering abortions, while 12 states require all fully insured plans to include abortion coverage.
If Republicans’ proposal became law, residents of the 12 states that require abortion coverage who get health coverage under the ACA — around 3.7 million people in 2023, according to KFF — could not use federal subsidies for marketplace plans.
Smith, a former leader for Planned Parenthood in Minnesota, said Republicans’ demands were “a huge overreach” that would dictate what kind of coverage private insurers can offer.
“If you’re talking about creating policies that are going to drain more people away from the insurance markets, then that is going to destabilize health insurance for everybody in this country,” Smith said.
Sen. Elizabeth Warren (D-Massachusetts) called the proposal in a statement “a backdoor abortion ban.” Sen. Tammy Baldwin (D-Wisconsin) said the demand was one of an array of policies that Republicans have championed since the Supreme Court overturned Roe v. Wade in 2022 that would move the country closer to banning abortion altogether.
“They’re going at it in all sorts of ways, but if you look at this policy plus that policy, that’s really the end result,” Baldwin said in an interview.
Senate Democrats are also facing pressure from outside groups to stand strong on abortion policy in any deal.
“We are counting on and urging our champions in Congress who support abortion access to remain firm in their stance that any negotiations about extending ACA premium tax credits must not include additional abortion restrictions,” Amy Friedrich-Karnik, the director of federal policy for the Guttmacher Institute, which supports abortion rights, said in a statement.
Some senators are optimistic that they can find a path to extending the ACA subsidies that will satisfy both sides. Congress has had to navigate thorny challenges around abortion during every major health care debate.
“We deal with Hyde all the time,” said Sen. Lisa Murkowski (R-Alaska), one of the few Senate Republicans who supports extending the subsidies as written. “It’s not easy, but we deal with it.”
Others are more skeptical.
“The Hyde Amendment is already on the ACA tax credits, and has been for a while,” said Sen. Ruben Gallego (D-Arizona). “What they’re trying to propose is happening, that’s not happening right now. I think this might be them trying to get out of voting for the tax extension.”
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