Watch the live stream: The Senate meets as the government shutdown enters the twenty-third day

WASHINGTON (AP) — The government shutdown has reopened debate on what has been a central issue for both major political parties in the past 15 years: the future of health coverage under the Affordable Care Act.

Watch the Senate debate in the player above.

Tax breaks for people who get health insurance through the marketplaces created by the Affordable Care Act, also known as Obamacare, expire at the end of the year.

Read more: US debt stands at $38 trillion, following the fastest $1 trillion accumulation outside the pandemic

Democrats say they will not vote to reopen the government until Republicans negotiate an extension of the expanded benefits. Republicans say they will not negotiate until Democrats vote to reopen the government. Lawmakers in both parties are working on potential solutions behind the scenes, hoping that leaders will eventually start speaking up, but it is unclear whether the two sides have reached a compromise.

While Congress grapples with the issue, a poll by The Associated Press-NORC Center for Public Affairs Research found that about 6 in 10 Americans are “extremely” or “extremely” concerned about rising health care costs in the coming year. The survey found that these concerns span across age groups and include people with and without health insurance.

A look at expiring benefits, ACA policy and what Congress could do:

Enhanced premium assistance during the pandemic

Passed in 2010, the ACA was intended to reduce the number of uninsured people in the country and make coverage more accessible to those without private insurance. The law created state-by-state exchanges, some of which were run by individual states, to try to increase the pool of insured and lower prices.

In 2021, when Democrats took control of Congress and the White House during the COVID-19 pandemic, they expanded premium aid that was already in the law. The changes included eliminating premiums for some low-income enrollees, ensuring that the highest earners pay no more than 8.5% of their income and expanding eligibility to middle-class earners.

Expanding subsidies has pushed school enrollment rates to new levels and pushed the rate of uninsured people to a historic low. This year, a record 24 million people registered for insurance coverage through the ACA, largely because billions of dollars in subsidies made the plans affordable for many more people.

If the tax credits end, out-of-pocket annual premiums are expected to increase 114% — an average of $1,016 — next year, according to an analysis by KFF.

Democrats are pushing to extend benefits

Democrats extended these tax breaks in 2022 for another three years, but were unable to make them permanent. The appropriations are set to expire on January 1, with Republicans now in full control.

Lacking power and sensing a political opportunity, Democrats used some of their only leverage and forced the government to shut down over the issue when federal funding ran out on October 1. They say they will not vote for a House-passed bill to reopen the government until Republicans give them some certainty that support will be extended.

Democrats introduced legislation in September to permanently extend premium tax credits, but noted they were open for a shorter period.

Senate Democratic Leader Chuck Schumer has repeatedly said: “We need serious negotiations.”

Republicans are trying to shrink the Affordable Care Act again

Democrats’ health care demand has reignited Republicans’ long-standing complaints about the Affordable Care Act, which they campaigned against for years and tried and failed to repeal in 2017. Many in the party say that if Congress were to act, they want to repeal the expanded benefits and overhaul the entire law.

Republican Sen. Rick Scott of Florida said Tuesday that the problem is not the expiration of subsidies, but the “cost of health care.”

In a virtual news conference Tuesday, the libertarian Cato Institute and the conservative Paragon Health Institute described the subsidies as President Joe Biden’s “Covid credits” and claimed they enabled scammers to enroll people in fully subsidized plans without their knowledge.

Others have offered more modest proposals that could win over some Democrats. Senate Majority Leader John Thune, R-S.D., said he is open to extending benefits with changes, including lower income limits and halting automatic enrollment that would enroll people who don’t need coverage.

Thon said the anti-corruption body “is in dire need of reform.”

House Republicans are considering their own ideas for reforming the Affordable Care Act, including proposals to phase out subsidies for new enrollees. They have begun discussing whether to combine the health care reforms with a new government funding bill and send it to the Senate for consideration once they return to Washington.

“We’re probably going to have to negotiate some bumpy roads” to ease the transition to pre-COVID-19 levels, Maryland Rep. Andy Harris, chairman of the conservative House Freedom Caucus, said during a virtual town hall on Tuesday.

Is settlement possible?

A number of Republicans want to extend the benefits. Sen. Josh Hawley, Republican of Missouri, said most people who use the exchanges created by the ACA “don’t have another choice, and it’s already very expensive. So I think there are things we can do to fix the program.”

Hawley said he has had conversations with other senators about what those changes might be, including proposals for income limits, which he said he finds “very reasonable.”

Bipartisan groups of lawmakers have discussed income limits and other ideas, including making low-income people pay very low premiums instead of nothing. Some Republicans have called for this change to make sure all enrollees know they have coverage and need it. There are other proposals to extend the subsidies for a period of one or two years or to phase them out gradually.

It is unclear whether any of these ideas would gain traction on both sides — or any interest from the White House, where President Donald Trump has remained largely aloof. Despite the overall stalemate, lawmakers feel increasing urgency to find a solution as the Nov. 1 open enrollment deadline approaches.

Democratic Senator Jeanne Shaheen of New Hampshire has been speaking with lawmakers since the shutdown began, trying to find areas for compromise. She suggested Tuesday that Congress could also consider extending ACA enrollment deadlines since Congress is stuck on benefits.

“These costs will affect all of us, and will impact our health care system,” she said.

Associated Press writers Lisa Mascaro and Joey Cappelletti in Washington and Ali Swenson in New York contributed to this report.