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Pressure on Congress to renew expiring enhanced Affordable Care Act subsidies is likely to ramp up this fall as notices of 2026 premium increases go out and consumers get their first warnings that huge rate hikes could be coming.

Why it matters: Backers of renewing the enhanced tax credits, which expire at the end of this year, hope the sticker shock could motivate Republicans to get behind a short-term reauthorization to avoid an uproar over premium increases in an election year.

What they're saying: "This is going to rain starting in October; people are going to start getting these notices," said Leslie Dach, chair of the Democratic-aligned group Protect Our Care. "And it comes right to your doorstep, right to your mailbox."

• Republicans in Congress, he said, are not "going to do anything until they see the light of their constituents' eyes here … so the most important thing is to be sure people know what's going on."

The big picture: Out-of-pocket premium costs for over 20 million enrollees in the ACA marketplaces will increase by an average of 75% if the enhanced subsidies expire at the end of this year, according to KFF. Congressional scorekeepers also project 4.2 million more people would become uninsured over a decade.

• That puts Republicans in a bind heading into the midterm elections: stuck between resisting an expansion of the ACA and the fear of steep health cost increases for their constituents.
• Although some GOP lawmakers are open to a deal on an extension, there's substantial concern over the projected $335 billion cost over 10 years — and the often-expressed sentiment that the subsidies are a handout to insurance companies.

Between the lines: When exactly people will get notices about premium increases for next year depends in part on whether they are in one of the 20 states that run their own ACA marketplaces, where notices typically go out earlier.

• Insurers at a minimum must send notices before Nov. 1, when sign-ups for next year begin.
• Those notices tend not to have completely up-to-date individualized information, so many people likely will not see exactly how much more they will pay.
• But this year insurers are in discussions about how best to make clear that the enhanced subsidies are expiring. They're likely to include language informing people and telling them to check the healthcare.gov portal for the exact premium increase.
• "I think that this could turn into quite a political issue for an important voting bloc, and frankly, a constituency that the data suggests swung more heavily toward Republicans in the last elections," said Ceci Connolly, CEO of the Alliance of Community Health Plans. "This will hit pocketbooks directly."

The other side: Brian Blase, president of Paragon Health Institute and a health official in the first Trump administration, said that when the enhanced subsidies were originally passed in 2021 they were meant as a "temporary COVID measure," and that it was Democrats who set them to expire.

• "How are they going to come up with that amount of money" to pay for an extension? he asked. "I mean, that's a huge chunk of change, and these are subsidies that go directly to health insurers."

Trump health officials are considering a policy that would limit hospitals' ability to participate in Medicare and Medicaid if they perform gender-affirming medical procedures for transgender youth.

The big picture: Hospitals are highly dependent on payment from public health insurance.

• Medicare and Medicaid covers at least two-thirds of inpatient days at more than 80% of hospitals, according to the American Hospital Association.

State of play: The proposed policy change landed at the White House for review yesterday, according to the Office of Information and Regulatory Affairs' website.

• The rule is expected to prevent hospitals that provide gender-affirming procedures for minors from getting paid by Medicare or Medicaid, the National Review reported.

Trump administration health officials didn't respond to questions about which procedures or services would be prohibited.

• CMS told Axios that it doesn't comment on potential future regulations but that future CMS actions will continue to support President Trump's executive order to defund gender-affirming care for minors.

Zoom out: Many hospitals — even in deep-blue states — have already pulled back from providing transition-related services for minors over fear of losing federal funding based on previous Trump administration actions.

• 16 states last week sued the administration over the funding threat and other actions, including investigations of hospitals and demands for patient data.

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UnitedHealth Group and Amedisys yesterday moved to complete their $3.3 billion merger by agreeing to a proposed settlement with the Justice Department under which they'll divest 164 home health and hospice properties.

Why it matters: The deal had been tied up in courts over regulators' concern it would give UnitedHealth too much market power. Had it gone to trial, it would have likely been the Trump administration's first major health care antitrust case.

What's inside: The proposed agreement filed in U.S. District Court in Maryland would require the companies to divest home health and hospice locations across 19 states that account for about $528 million in annual revenue.

• Amedisys would also pay a $1.1 million civil penalty for falsely certifying that it provided "true, correct and complete" responses during the antitrust review.
• The Justice Department said it was largest divestiture of outpatient health care services to resolve a merger challenge, as measured by the number of facilities.

Catch up quick: The Biden administration sued in November to block the deal, joined by attorneys general of Maryland, Illinois, New Jersey and New York.

• The companies had previously offered to sell an undisclosed number of clinics. UnitedHealth's Optum unit at the time called the suit an overreaching interpretation of antitrust laws.
• UnitedHealth already had a major footprint in home care through its purchase of LHC Group.

What's next: The proposed settlement still has to be approved by the court after a public comment period.

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