Lawmakers are in ACA exchange plans too, but a generous employer contribution shields them from the premium cliff that millions of families now face.

As Congress argues over whether to extend enhanced Affordable Care Act (ACA) subsidies that were implemented during COVID, millions of Americans are watching the clock tick down toward a possible premium shock at the start of next year. Independent analysts estimate that if the enhanced premium tax credits expire at the end of 2025, average Marketplace premiums paid by enrollees would more than double. Families in the individual market who do not have employer coverage or Medicaid may soon face hard choices about whether they can afford to stay insured at all. 

That raises a simple question. What kind of coverage do the members of Congress who will decide this debate have for themselves and their families? 

In fact, the ACA includes a provision that the only health plans the federal government may make available to members of Congress and certain congressional staff, for their service in those roles, are plans offered through an ACA exchange. Before the ACA took effect, members and staff enrolled in the Federal Employees Health Benefits (FEHB) program like other federal workers. Afterward, they had to move into the exchange system they had just created. 

To implement that requirement, the Office of Personnel Management directed that members and designated staff would obtain employer sponsored coverage through the Small Business Health Options Program exchange in Washington, DC, known as DC Health Link. In practice, their congressional office is treated as a small employer that buys group coverage on the DC SHOP exchange. Members and eligible staff choose from the same menu of DC Health Link SHOP plans that other small employers in the District can purchase for their workers. 

The crucial detail is how those plans are financed. The ACA provision that moved Congress into the exchanges did not specify what would happen to the employer contribution members and staff had previously received under FEHB. OPM decided that the federal government would continue to pay its usual share of premiums, using the same formula that applies to most federal employees. Under that formula, the government pays roughly three quarters of the premium cost in many plans, with the enrollee paying the rest through payroll deductions. 

That means a member of Congress who signs up through DC Health Link gets a large and predictable employer subsidy. The government pays most of the premium, and the member’s share looks like a typical large employer plan. They do not also claim ACA premium tax credits, because they are in an employer sponsored plan and their incomes are well above the thresholds for subsidy eligibility.  

Members of Congress, by contrast, do not face that kind of cliff. When premiums for DC Health Link plans go up, the federal contribution is recalculated under the FEHB-style formula. That contribution is not tied to the ACA’s temporary premium tax credit enhancements. It is an ongoing employer benefit that provides substantial insulation from premium spikes. Lawmakers may see higher payroll deductions when health costs rise, but the scale of those increases is nothing like the potential doubling of premiums that many Marketplace enrollees could see if Congress does not find a common ground solution by year end. 

Such a solution is now on offer from Reps. Josh Gottheimer and Jenn Kiggans, and a bipartisan group of 35 other members that would extend ACA subsidies, reduce eligibility for higher-income beneficiaries and put in new provisions to crack down on fraud. 

So, while members of Congress are structurally inside the ACA system, financially they look much more like workers with a generous large employer plan than like the millions of people who rely on the individual market. They choose among commercial plans on an ACA exchange, but they do so with a built-in, taxpayer funded subsidy that covers most of the cost. They do not have to navigate the subsidy cliff that their constituents are now worried about. 

That disconnect matters. It means the people who are about to decide the fate of the enhanced tax credits are not personally exposed to the same risk. If Congress fails to act, it will not be members and their families who see their premiums double in January. It will be self-employed workers, people in small firms that do not offer coverage, and families who turned to the Marketplace after losing employer insurance. 

No one is arguing that members and their staff should lose their health benefits. The federal government should be able to attract and retain capable employees, and that requires competitive coverage. But when lawmakers have the security of a stable, employer-funded plan, they have a special responsibility to protect people who do not.