The House on Wednesday passed a Republican-backed health care package by a vote of 216–211 that does not include an extension of expiring Affordable Care Act (ACA) subsidies, sending the measure to the Senate, where it is expected to stall.

The vote came as Congress prepares to leave for the holiday recess, raising the likelihood that millions of Americans will face higher health insurance premiums when the enhanced ACA subsidies expire.

Four moderate Republicans — Reps. Brian Fitzpatrick, Mike Lawler, Rob Bresnahan and Ryan Mackenzie — who earlier in the day broke with GOP leadership by signing onto a Democratic-backed discharge petition to force a vote on extending the subsidies, ultimately voted in favor of the Republican package. Rep. Thomas Massie was the lone Republican to vote against the bill.

Earlier Wednesday, House Speaker Mike Johnson rejected suggestions that he has lost control of the chamber after the moderates joined Democrats’ effort to advance a three-year extension of the ACA subsidies.

“We have the smallest majority in U.S. history,” Johnson said. “These are not normal times. When you have a razor-thin margin, all the procedures in the book are on the table.”

The four Republicans’ decision to sign the discharge petition gave it the 218 signatures needed to force a vote on the ACA extension, though such a vote is not expected until January 2026 at the earliest.

Their move followed a decision Tuesday night by the Republican-controlled House Rules Committee to block amendments that would have extended the subsidies. Johnson has also declined to allow a direct floor vote on the extension, which was a central issue during the record 43-day government shutdown earlier this fall.

When asked whether he would allow a vote on the ACA extension next year, Johnson said, “Everybody stay tuned. We are having conversations.”

Johnson was seen conferring with moderate Republicans on the House floor during Wednesday’s votes and described the discussions as productive.

“We just had some intense fellowship,” he said. “We’re working through very complex issues, as we do here all the time. Everybody’s working toward ideas, and we’re keeping the conversation going.”