The Waiting Room | Tuesday's Mini-Blue Wave Didn't Change Healthcare Policy — but It Should Strengthen Dems' Hand

Welcome to Lincoln Square's latest newsletter that cuts through all the confusion of health care under Trump 2.0.

Greetings, Lincoln Square readers!

I’ve been asked to contribute a biweekly roundup of the latest developments in the batcrap crazy world of U.S. healthcare policy (which is at a particularly batcrap level at the moment).

The goal of this newsletter is to break down health policy at a time when insurance rates are soaring — and help you navigate the (sometimes nonsensical) changes we’re seeing from the Trump administration.

So Who Am I?

In 2013, when neither the government nor the mainstream media provided consistent, reliable reporting of enrollment data for the just-launched Affordable Care Act, I launched ACASignups.net primarily as a data-wonk hobby, using crowdsourcing to track enrollments in real time.

I eventually became known as one of the most reliable sources for All Things Obamacare-related during that critical first Open Enrollment Period. One thing led to another and somehow what had started as a nerdy way of taking a break from my day job as a freelance website developer became a completely unintentional full-time career.

Over time, I expanded my healthcare policy knowledge base and analysis chops to include a fuller understanding of the ACA’s Medicaid Expansion and BHP provisions, tracking annual premium rate changes and numerous other ACA-related policies, as well as keeping track of and analyzing the U.S. healthcare system as a whole.

Over the years, my work has been cited and used as a resource by various major media outlets spanning the ideological spectrum, from the New York Times to the Bulwark.

I’ve also served stints as a healthcare data consultant for the Center for American Progress as well as on Board of Directors of Doctors of America (despite … or perhaps because of … not being a physician myself).

Like most of the best people in the world 😉, I live in Michigan (with my wife and son).

I also publish my work at ACASignups.net and Substack, and you can follow me on Bluesky at @charlesgaba.com.

The pilot edition of this newsletter will be pretty much 100% ACA-focused, with good reason. Not only is it the heart of what I write about, but it’s also sucking nearly all of the oxygen out of the healthcare policy news department in recent weeks.

Tuesday’s Blue Wave

But first, a quick shout-out to Tuesday’s election results, where Democrats delivered a massive, unmistakable beatdown of Donald Trump and Republicans just about everywhere they had the opportunity to do so.

In terms of state-level healthcare policy, this mostly means that New Jersey will be able to continue things like their Health Plan Savings program, which is backfilling around 40% of the lost federal ACA tax credits. New Jersey Governor-elect Mikie Sherrill’s campaign site talks about protecting reproductive rights, lowering prescription drug costs by cracking down on Pharmacy Benefit Managers (PBMs) and pricing transparency.

For Virginia, Democrats winning a solid trifecta including a solid majority in the legislature means they’ll be able to push forward with a constitutional amendment enshrining reproductive rights. The only specific healthcare policies Governor-elect Abigail Spanberger mentioned on her campaign site are, again, lowering prescription drug prices and protecting Medicaid expansion.

As for New York City (not a state but a special case), it’ll be interesting to see how Mayor-elec Zohran Mamdami’s bold agenda fares. He didn’t really emphasize healthcare policy that much in his campaign, but his website does mention boosting healthcare system navigators, boosting hospital funding and rejecting Medicare Advantage, so we’ll see how that goes.

In terms of federal policy, yesterday’s results won’t technically change anything since neither the U.S. House nor Senate were on the ballot … but it should serve to strengthen Senate Democrats’ position substantially when it comes to holding their ground on their government shutdown demands, which are largely healthcare policy-related.

Speaking of which …

• The annual ACA Open Enrollment Period (OEP), during which you can shop around for and enroll in private healthcare coverage if you aren’t eligible for other programs like Medicare, Medicaid, CHIP or coverage through your employer (w/some exceptions) began on November 1st nationally (Idaho launched their OEP a couple of weeks earlier).

• In most states, you have until December 15th to enroll for coverage starting January 1st.

• See my annual Open Enrollment Guide for a lot more details on what to look for when enrolling for 2026.

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The biggest elephant in the room for ACA Open Enrollment this year is, of course, the pending expiration of the beefed-up premium tax credits which have been in place for the past five years. As anyone not in a coma should know by now, these are scheduled to expire on December 31st, meaning that

• The expiring tax credits, along with other factors such as Trump’s tariffs, the so-called “Marketplace Integrity & Affordability Rule” (some provisions of which have been placed on hold for now via a court order) as well as “non sabotage” factors like standard medical inflation, increased service utilization and carriers covering expensive new drugs like GLP-1 have resulted in average gross (unsubsidized) 2026 ACA policy premiums increasing by a weighted average of nearly 26% nationally.

• I can’t stress this enough: That 26% is for gross premiums only…which means that’s how much they’ll increase for the ~3 million people or so (half on-exchange, half off-exchange) already paying full price.

• The remaining 21 million exchange-based enrollees who are currently receiving federal tax credits are looking at dramatically higher rate increases, averaging 114% overall, but with potentially 200%, 300% or even higher increases in some cases.

As if that wasn’t enough, the maximum out-of-pocket ceiling (MOOP) for ACA enrollees is also increasing by $450 per person or $900 more per household than it otherwise would have due to a formula change made by the Trump regime (MOOP is the maximum amount that enrollees have to pay in deductibles, co-pays and coinsurance for in-network services beyond which the insurance carrier has to pay 100%).

Most of my advice on 2026 Open Enrollment is included in the guide I posted last week, but I also wanted to touch on three additional points which are specific to enrollees who expect to earn more than 400% of the Federal Poverty Level (FPL) next year.

As a reminder, 400% FPL will be $62,600 for a single adult, $84,600 for 2 people, $106,600 for 3 and $128,600 for a family of four. Due to the expiring subsidies, if your MAGI (Modified Adjusted Gross Income) is even $1 over that next year, you lose eligibility for any federal ACA tax credits, which is causing a lot of the crazy high rate hike estimates you’ve likely seen floating around.

1. Hold your Fire

The very first item on my annual enrollment guide urges people not to delay (to avoid missing the December 15th deadline). This is still good advice in general, but this year it includes a major caveat: As unlikely as it seems, there could still be a last-minute deal by Congress to extend the enhanced tax credits by another year or longer.

If this does happen, it will have a major impact on enrollment decisions for millions of ACA enrollees…so you might consider holding off a few weeks to see what developes. Just don’t wait too long, however, or you could find yourself with a coverage gap for January (or the entire year, if you live in Idaho, since December 15th is the final 2026 OEP deadline there).

2. Silver Switching

The fourth item on my enrollment guide advises people who are currently enrolled in off-exchange ACA plans (that is, directly through the insurance carrier instead of via an ACA exchange website) to consider doing so on-exchange instead, just in case you turn out to be eligible for tax credits after all.

Again, this is still good advice, but again, there’s an important caveat: There are some people in some states who might be better off enrolling in an OFF-exchange Silver plan specifically, in order to avoid the “CSR premium load.” These off-exchange plans are generally called “Mirrored Silver” and are only offered by certain carriers in certain states.

This process is called “Silver Switching.” I wrote a full explainer up about it 8 years ago which hasn’t really been relevant since 2020, and plan on posting an updated version soon.

I only advise people to consider doing this if a) they’re absolutely certain they won’t be eligible for tax credits next year and b) they’re better off with a Silver plan than Bronze, Gold or Platinum.

3. Chasing 400

If you expect your 2026 income to be slightly over 400% FPL, there are several perfectly legal ways to get it back down below that threshold. This mostly involves things like putting money into an IRA or enrolling in a policy which includes a Health Savings Account (HSA).

I’m neither an accountant nor a tax attorney, however, so I’d consult one before pursuing this course of action. Because if you receive federal tax credits based on your projected income but your actual 2026 income ends up being more than you thought, you’ll have to pay some or potentially all of it back when you file your taxes in early 2027…which would sting if you earn less than 400% FPL but could be devastating if you end up over that threshold.

As noted above, I plan on writing more detailed posts about both Silver Switching and Chasing 400 soon.