In this five-part series, C-VILLE examines the consequences of Congressman John McGuire’s 2025 vote for HR1, also known as the One Big Beautiful Bill. Its sweeping cuts to social safety net programs will affect tens of thousands of McGuire’s constituents in Virginia’s 5th District. This week, in part two, we investigate how McGuire and HR1 drove up constituents’ costs for health care plans from Virginia’s insurance marketplace.
Congressman John McGuire spent time in foster care as a child. Today, someone like Stephanie Cangin, 58, would look out for him under the law. Cangin works as a guardian ad litem. When custody, foster care, or other cases involving children go to court, she advocates for the children involved.
She spends her days driving back and forth between court hearings and home visits. She takes medicine for prediabetes, high cholesterol, and high blood pressure. And from December 2025 to January 2026, her health insurance premiums surged by 67 percent, to nearly $1,000 a month.
She could have switched to a plan with lower premiums, but “I was figuring that the out of pocket was going to be too insane if I tried to do that. I’m not young, so, you know, the older you get, the more health issues come up.”
“I’m cutting back in general,” Cangin says when asked how the price hike has affected her life. “Everything’s more expensive right now. So, no vacations. I guess I’m working more hours. It’s hard to tell exactly.”
“I’ve got a real heart for health care,” McGuire says, saying the existing system is broken. But Cangin’s higher costs owe directly to McGuire’s vote for Republicans’ HR1 budget bill last May.
Enhancements eliminated
In voting for HR1, McGuire sealed the fate of the Affordable Care Act’s enhanced premium tax credits. They helped more people afford health insurance plans through an ACA exchange. Under the Biden Administration, Congress increased these credits as part of its post-COVID recovery bills in 2021 and 2022.
A report from Johns Hopkins found that these enhanced credits helped many more Americans get insured. The percentage of Black Americans getting health care through the exchange more than tripled. Enrollment among eligible rural Americans and children under 18 doubled. Latino Americans’ participation grew by around 75 percent. And part-time workers’ enrollment grew by two-thirds. Compared to 2018-2019, 2.3 million more Americans stayed enrolled on their exchange health plans in 2021-2022.
“They just suck,” McGuire said of the enhanced subsidies in a December 2025 appearance on conservative commentator John Fredericks’ radio show.
Enhanced credits were due to expire in 2025. HR1 could have renewed them, but didn’t. As a result, many people with ACA plans saw their prices spike in January, with the increases varying depending on age, income, and other factors.
Charles Gaba has tracked data related to the Affordable Care Act since 2013 at his site acasignups.net. Based on prior-year figures and statewide drops in enrollment, he estimates that as of February 2026, roughly 33,500 people in Virginia’s 5th District—around four out of every 100 residents—were enrolled in an ACA plan.
Gaba provided C-VILLE with charts showing the expected premium hikes for different types of people in Charlottesville enrolled in one of the exchange’s popular Silver plans. In many cases, the data shows prices rising by the greatest percentages for people at the lower-middle and highest ends of the income distribution.
Consider average rates for a family of four with 40-year-old parents and 15- and 12-year-old children. Without enhanced tax credits, their monthly premiums surge from less than $50 to nearly $200 for families making $50,000 a year. They roughly double for families making $60,000 to $80,000. Prices rise about 50 percent for families making $90,000 to $100,000, and about 33 percent for families making $110,000. Families making $130,000, above the eligibility range for tax credits, see premiums spike from $884 to $1,652 a month.
At the extreme end of the increases, a 63-year-old couple making $90,000 a year would go from paying $638 a month to $2,345. Charts for Danville and Lynchburg showed similar increases across the board.
The premium hikes from the credits’ termination seem poised to reverse the lower uninsured rate they enabled. A recent report from the Centers for Medicare and Medicaid Services found that 1.2 million fewer people nationwide enrolled in ACA exchange plans during this year’s open enrollment period. In Virginia, 33,000 fewer people had signed up as of April 3, which the head of the state’s exchange described as “the biggest drop-off in the first quarter that we’ve ever seen.”
That number could grow in the months ahead. ACA plans give patients a 90-day grace period before kicking them off coverage for not paying their premiums. Experts say the full data on coverage losses after this period won’t arrive until at least July. A May 2026 analysis by the Kaiser Family Foundation projected that the loss of tax credits would drive at least 5 million Americans out of the ACA marketplace nationwide by the end of the year.
Did the ACA cost too much?
“With all due respect, I think it should be called the Unaffordable Care Act,” McGuire says, “because it benefited insurance companies.” He says the ACA “caused premiums to go up 26 percent every year.” He didn’t cite a source for that statistic.
“Your congressman is utterly full of shit,” says Gaba. “If ACA premiums had increased 26 percent per year on average since 2010, they would be more than 3,900 percent higher today than they were then.” (We invited the congressman and his staff to respond to apparent factual errors or disputed data in his statements, but they declined.)
Gaba’s data shows that the average cost of ACA premiums has risen a cumulative 166 percent since 2010, from $278 per month to $741. That’s about three times as fast as inflation, and a bigger overall hike than private, employer-sponsored health insurance. Private premiums increased 107.5 percent in the same period. But employer plans started out with higher premiums, meaning they’re still more expensive than ACA plans on average—nearly 12 percent costlier.
Even when you factor in ACA plans’ higher average deductible costs, the enhanced subsidies made the total amount people paid per month for health care through an ACA plan roughly the same as employer coverage. Now that HR1 has killed enhanced credits, Gaba’s numbers show ACA plans’ total costs to consumers are about 25 percent higher than employer plans.
“The exchanges at their largest only had 24 million people,” says Prof. Melanie Anne Egorin, a health policy expert at UVA’s Batten School of Leadership and Public Policy. “Less than 10 percent of the American population is covered in the individual markets. … The employer-sponsored insurance market is about 160 million people. It’s about half of the U.S.”
“The largest tax expenditure in the U.S. tax code is employer-sponsored insurance,” she says, “because the employer gets a tax deduction and the employee gets a tax deduction for purchasing health insurance.”
McGuire says the ACA’s enhanced credits were too expensive to renew. “If you have $20, you can’t spend $1,000. We’ve got to make sense.” But the government loses more money each year on tax breaks for employer plans—$299 billion in 2022— than it spends on ACA tax credits, which cost $138 billion in 2025.
Meanwhile, since HR1’s tax cuts exceed its spending cuts, the Congressional Budget Office predicts that the bill will add $2.7 trillion to the national deficit between 2025 and 2034.
Egorin says the ACA made sure insurers provided essential services like preventative care. And it prevented insurers from denying people coverage, or charging them more, because of preexisting conditions. McGuire’s proposed alternative to the ACA, she says, might not have those same protections.
Free association
McGuire says the enhanced premiums strayed too far from what he calls the ACA’s original intent to “help folks that were impoverished and having a hard time getting health care.”
“What we did in the One Big Beautiful Bill is … basically we let them expire, which they would have done anyway,” he says. “But we countered that with an opportunity to have you pool your resources.”
McGuire’s talking about association health plans, modeled on long-available plans that let groups like farmers band together to purchase insurance at a lower rate than they could get individually. “If you went to a Ford dealer to buy one pickup truck, you’d probably pay close to the top dollar amount,” McGuire explains. “But if you told the Ford dealer, ‘I’m going to buy 50 F-150s,’ you could probably negotiate a lower price.”
McGuire says the ACA plan he’s on as a member of the government didn’t cover several procedures his wife needed, though he didn’t provide further details. “My opinion, based on my life experience, is that it should be free market competition to drive innovation and drive down prices and give you choices across state lines, and that way you can shop around,” he says.
“This is where the devil’s in the details,” Egorin says. Association plans don’t have to meet the same standards as ACA plans; they could charge less, but offer worse care in exchange. And while the ACA offers care to everyone, association plans can exclude sick people in favor of more profitable healthy customers. “Unlike an employer, who doesn’t get to choose who they employ based on their health status, or their family members’ health status, association health plans can. So it’s a highly discriminatory way of creating collective risk.”
In this scenario, lower prices wouldn’t guarantee a better product, Egorin says. Competition across state lines could touch off a race to the bottom, as employers vie to offer the least care in states with the fewest regulations. “Everybody’s gonna go to Delaware, like on credit cards,” Egorin notes. “In the plans, you can see [that] even people with highly regulated plans are still bad actors, or still very creative in their thinking.”
Asked whether she’d sign up for an association health plan, Cangin says, “Absolutely not, because I’m pretty sure I’d be excluded because, you know, I’m older, and I have … preexisting conditions.”
It’s not clear that she’d even be able to find an association to purchase care with. “What you call a guardian ad litem varies by state,” she says. Some states hire lawyers for the job, while others have court-appointed special advocates, and still others provide those services via government agencies. “Not everybody’s a lawyer, so you can’t band together across state lines. And we all get paid a different rate.”
An ounce of prevention
“Your first car probably came with an owner’s manual,” McGuire says. “It said, at 200 miles, do this, at 400 miles, do this, at 1,000 miles, do this. … I think we need to educate our community and create a preventative health care system and catch problems early, not later.”
“The ACA already does this,” Egorin says. “Preventive care is established by the U.S. Preventive Services Task Force.” Normally, the panel meets three times a year to help set standards for screenings and tests that can catch sickness early. Under the Trump administration’s Department of Health and Human Services, it hadn’t met for more than a year as of March 2026. The task force’s web site has issued no news releases since August 2025.
Under HR1, “fewer people are covered by health insurance, so right there, their access to preventive care disappears,” Egorin says. “States have less dollars to invest in preventive health care services and public health.”
She predicts preventive care will suffer most in rural areas, where projections show hospitals will lose significant revenue under HR1. Rural hospitals often “go out in communities and do public health campaigns. They talk about diet and exercise. They talk about preventive health screenings,” she says.
The sky-high costs of medical school drive students toward more lucrative specialties, even though we need primary care doctors more. “If Congressman McGuire wants to make prevention better, you need to pay primary care providers, doctors and nurses, more, and we need to pay specialists less,” Egorin says. “The incentives right now for health care delivery and who provides health care is incredibly messed up.”
Egorin seems worn down by the endless debate. “Why are we still having this fight?” she says. “I think American consumers are feeling the price of health care because we are still fighting about whether the ACA was good or not. And I would argue it is good. It reduced the number of uninsured, it got people a quality benefit, and made health care accessible, not just in the ACA exchanges, but across the board. It brought the standard of care up. It changed how hospitals behave to be more about the patient.”
“If Republicans’ ideas are ways to undermine care, through junk plans, through kicking people off of health insurance, or not strengthening consumer protections, they’re not bringing a lot to the conversation about what actually drives down the cost of health care,” she says.
When asked what she loves about her job, Cangin says, “Helping kids. I mean, that sounds pretty basic, but that’s kind of what it is.” But when she considers her future, she says the sudden, sharp rise in her premiums has changed her outlook. “I think that I’m having to consider, you know, can I keep doing this?”
“Certainly I have a heart,” McGuire says upon hearing about people struggling with higher premiums. “I’m a Christian. I want to be like Jesus, but we have to make sense with our budget.”
Next week: HR1 toughens work requirements and caps spending for SNAP food aid, as local agencies report rising food insecurity.
