Congress has left for the year without reaching a health care deal, leaving Affordable Care Act subsidies that have helped lower insurance prices for roughly 22 million Americans to expire on Dec. 31 without taking action to address the surge in costs that is expected to follow.

As the end of the subsidies looms, families and individual Americans are bracing for immediate impacts. Monthly payments for millions of ACA marketplace enrollees are set to double or even triple without the tax credits that have made their premiums cheaper. The Congressional Budget Office has estimated that the lapse could leave roughly 4 million more Americans uninsured, with analysts warning of broader impacts over the coming years.

The enhanced subsidies were introduced during the COVID-19 pandemic and extended by Democrats in 2022. For many lower-income Americans, they have resulted in free or nearly free coverage. For higher-earning recipients, they have dramatically reduced premiums. The lowered costs have contributed to a surge in enrollment, particularly among Americans in Republican-led Southern states, where coverage previously lagged.

Read more: What the End of Obamacare Subsidies Could Mean for Your Health Coverage

Democrats have pushed for months to further extend the subsidies, making it a key demand in the spending standoff that shut down the government this fall. A group of Senate Democrats ultimately broke with the party to reopen the government on the condition that a vote on an extension measure would occur in December. But lawmakers have now left Washington without holding one.

Four swing-district House Republicans did defy party leadership and join a Democrat-led discharge petition to force a vote on a three-year extension in the chamber. Speaker Mike Johnson, who refused to bring the issue up for a vote before the holiday recess, will be required to do so after Congress reconvenes in the new year. The vote is expected the week of Jan. 5 when the House returns to session.

Even if the bill passes the House when it comes up for a vote next month, Senate Republicans are likely to block it, as they did in the case of a similar Democratic proposal earlier this month. But some lawmakers have expressed hope that it could help lawmakers move closer to passing a health care bill.

“I do believe if the bill comes to the floor, not only will it pass, but it’ll give the Senate the ability to come back with a bipartisan compromise and actually get something passed into law,” Rep. Mike Lawler of New York, one of the Republicans who signed on to the discharge petition, said Wednesday on NBC’s “Meet The Press Now.”

Republican Sen. Susan Collins of Maine told NBC News that the House passing the bill would “keep momentum going,” but declined to voice support for it.

“What we’re trying to do is to put together a bipartisan bill that would have reforms plus a two-year extension,” Collins said. “That is the best approach, in my opinion, and we’re making good progress.”

Appearing on ABC’s “This Week” with Jonathan Karl, House Minority Leader Hakeem Jeffries brushed off comments from Senate Majority Leader John Thune, who said a clean three-year extension would be dead on arrival in the Senate. Jeffries said Thune “is not serious about protecting the health care of the American people.”

“It will pass, with a bipartisan majority, and then that will put the pressure on John Thune and Senate Republicans to actually do the right thing by the American people: pass a straightforward extension of the Affordable Care Act tax credits so we can keep health care affordable for tens of millions of Americans who deserve to be able to go see a doctor when they need one,” Jeffries said.

Republican Sen. Rand Paul of Kentucky, meanwhile, said Sunday he remains opposed to extending the subsidies, instead promoting an alternative health care proposal centered on expanding Association Health Plans, which would allow consumers to band together to negotiate lower insurance premiums.

Paul, earlier this month, was the only Republican senator to vote against a GOP proposal to establish government-funded health savings accounts.

“We have health care in our country for poor people. It’s called Medicaid. All of the rest of the stuff has not worked,” Paul said in an interview with Jonathan Karl on ABC. “Obamacare has been a failure. President Obama said it would bring premiums down; premiums have gone through the roof. Every time we give more subsidies, the premiums go higher.”

A Republican proposal passed by the House on Wednesday, which does not include an extension of the subsidies, also appears unlikely to get traction in the Senate. “I would expect the vote count if it were just purely this wouldn’t be probably the same as it was last week,” Sen. Thom Tillis, a Republican of North Carolina, told NBC News, appearing to reference the failure of a separate GOP bill in the Senate.

In the meantime, subsidies are set to return to pre-pandemic levels before Congress returns, leaving millions to navigate sharp premium increases. And amid the anticipated price changes, the deadline for open enrollment on the ACA marketplace for the year is fast approaching on Jan. 15. Experts have suggested some options for Americans to consider as they look for ways to keep their coverage more affordable.

Read more: Where Surging Obamacare Prices Could Hit the Hardest Next Year

Each party has pointed fingers at the other for rising health care prices. On Wednesday, President Donald Trump delivered a 20-minute-long address in which he blamed Democrats for the high costs while claiming his administration’s policies offered relief. “It's the Unaffordable Care Act,” he said. “The Democrats are responsible.”

Congressional Democrats, meanwhile, are placing blame on their Republican counterparts for failing to take action as the expiration date for the ACA subsidies approaches.

“Republicans still have a chance to lower costs on health care. But they still seem as determined not to as ever,” Democratic Sen. Elizabeth Warren of Massachusetts told Semafor.

Another deadline is also coming up in the new year: The short-term spending bill Congress passed in November, reopening the government, will only fund the government until Jan. 30, meaning it will once again shut down if lawmakers can’t reach a deal by that date.

Trump told a crowd of supporters at a rally in North Carolina on Friday that Democrats would again “close down the government,” accusing them of being “beholden” to insurance companies.

Senate Minority Leader Chuck Schumer, however, has insisted that Democrats will not link a spending bill to renewed subsidies in the new year. 

Speaking to Punchbowl News,Schumer noted that the enhanced Obamacare subsidies will have expired by Jan. 30 and said Republicans have shown they are incapable of striking a bipartisan deal. He added that Democrats feel they have succeeded in making health care a top issue for voters next November.

“As of Jan. 1, that is a different time than before because the ACA [subsidies] expired,” Schumer said. “On the other hand, we’d like to get an appropriations bill done. That’s a Jan. 30 deadline … We’re trying to work with the Republicans to get it done.”
“We’re working on appropriation bills to prevent another shutdown, now,” said Democrat Sen. Ben Ray Lujan of New Mexico, acknowledging the human stakes of legislative stalemate.“Let’s see what January brings. But people are hurting. Everything’s getting more expensive.”