It’s
been
a
week
since
the
nation’s
longest-ever
government
shutdown
ended,
but
millions
of
Americans
still
don’t
know
whether
they’ll
be
able
to
afford
their
healthcare
coverage
next
year.
The
shutdown
finally
ended
November
12
when
a
funding
bill
was
signed
into
law.
Notably
absent
from
the
law
was
any
extension
of
the
enhanced
Affordable
Care
Act
(ACA)
subsidies
that
24
million
Americans
rely
on
to
keep
their
premiums
somewhat
affordable.
Enhanced
ACA
tax
credits
were
introduced
during
the
pandemic
to
expand
healthcare
affordability,
and
they
are
set
to
expire
at
the
end
of
this
year
if
Congress
doesn’t
act.
This
year,
93%
of
ACA
marketplace
enrollees
received
the
tax
credits.
For
many,
these
expanded
subsidies
have
meant
the
difference
between
affording
routine
care
for
themselves
and
their
loved
ones
and
skipping
these
visits
entirely.
Experts
say
that
the
expiration
of
these
subsidies
wouldn’t
just
push
coverage
out
of
reach
for
millions
of
Americans
—
it
could
also
create
significant
challenges
for
hospitals
already
battling
financial
pressures,
as
well
as
potentially
hurt
the
economy
at
large.
Overall,
healthcare
leaders
have
a
number
of
concerns
about
what
could
happen
if
Congress
doesn’t
renew
the
expanded
tax
credits
—
premiums
could
increase,
a
larger
share
of
Americans
could
become
uninsured,
hospitals
could
be
forced
into
more
bad
debt
and
uncompensated
care,
and
most
worrisome,
American
public
health
would
further
deteriorate.
Soaring
premiums
could
be
on
the
horizon
When
the
ACA
health
insurance
marketplaces
launched
in
2014,
tax
credits
went
into
effect
to
make
coverage
more
affordable
for
individuals
and
families.
These
tax
credits
—
which
are
based
on
ACA
shoppers’
income
and
household
size
—
were
later
expanded
temporarily
under
the
American
Rescue
Plan
Act
in
2021,
and
then
extended
again
through
the
Inflation
Reduction
Act
in
2022.
As
a
result,
people
received
larger
subsidies
and
eligibility
criteria
was
broadened.
When
the
marketplaces
were
first
established,
the
government
provided
subsidies
to
people
earning
100-400%
of
the
federal
poverty
level,
and
individual
premium
contributions
ranged
from
2.07-9.83%
of
their
income.
The
American
Rescue
Plan
Act
and
its
extension
under
the
Inflation
Reduction
Act
boosted
these
subsidies
by
lowering
premium
contributions
to
0-8.5%
of
income
and
approved
$0
premiums
for
people
earning
100–150%
of
the
federal
poverty
level.
The
changes
introduced
during
the
pandemic
also
allowed
Americans
earning
above
400%
of
the
federal
poverty
level
to
qualify
for
subsidies
if
premiums
exceeded
8.5%
of
their
income.
These
credits
have
played
a
key
role
in
reducing
the
country’s
uninsured
rate
—
last
year,
the
national
uninsured
rate
reached
an
all-time
low
of
7.9%.
The
expiration
of
enhanced
tax
credits
would
turn
a
$460/month
premium
to
a
$700/month
premium
for
a
family
of
four,
said
ACA
marketplace
enrollee
Shana
Verstegen,
during
a
media
call
hosted
by
nonprofit
advocacy
group
Keep
Americans
Covered.
She
is
a
small
business
employee
at
a
gym
in
Madison,
Wisconsin,
along
with
her
husband.
They
rely
on
ACA
marketplace
coverage
for
themselves
and
their
two
children.
“Seven
hundred
dollars
per
month
in
2026
may
seem
like
a
small
number,
but
that’s
over
$2,500
a
year.
Right
now,
our
family
would
really
struggle
with
that
—
losing
that
tax
credit
would
create
a
real
crisis
for
us,”
Verstegen
remarked.
She
said
she
and
her
husband
have
discussed
the
possibility
of
him
leaving
the
job
he
has
loved
for
decades
to
secure
employer-based
coverage.
Not
only
is
this
a
difficult
and
emotionally
painful
decision,
it’s
also
one
that
needs
to
be
made
under
a
severe
time
crunch,
Verstegen
noted.
Open
enrollment
for
2026
ACA
coverage
is
already
underway,
with
deadlines
approaching.
Enrollment
must
be
completed
by
mid-December
for
coverage
starting
January
1,
leaving
little
time
for
families
like
the
Verstegens
to
adjust.
She
described
this
time
as
a
“really
tough
and,
quite
frankly,
scary”
moment
for
her
family.
“This
isn’t
about
politics
and
polling,
or
winners
and
losers
in
Congress,
or
red
or
blue
or
purple
states.
It’s
about
real
families
and
real
kids
—
real
people
who
need
healthcare.
Marketplace
coverage
and
the
premium
tax
credits
are
essential
for
entrepreneurs
and
small
business
employees
like
myself
to
afford
healthcare,”
Verstegen
declared.
Can
hospitals
handle
another
financial
hurdle?
About
22
of
the
24
million
people
who
have
ACA
insurance
will
see
their
premiums
double
if
the
tax
credits
expire,
and
5
million
are
expected
to
lose
coverage
completely,
said
Charlene
MacDonald,
executive
vice
president
of
public
affairs
at
the
Federation
of
American
Hospitals.
When
coverage
erodes,
hospitals’
levels
of
uncompensated
care
go
up.
MacDonald
said
hospitals
are
bracing
for
a
significant
uptick
in
uncompensated
care
—
especially
in
states
that
haven’t
expanded
Medicaid
coverage,
as
private
marketplace
plans
are
an
especially
critical
source
of
coverage
in
those
areas.
“Hospitals
treat
all
patients
who
come
through
their
doors
regardless
of
their
insurance
or
their
ability
to
pay
—
but
those
costs
don’t
disappear.
They
shift
back
onto
hospitals,
employers
and
taxpayers,”
she
explained.
This
strain
will
affect
all
healthcare
providers,
but
rural
and
safety
net
hospitals
will
be
hurt
the
most.
These
providers
tend
to
have
lower
patient
volumes
and
a
greater
share
of
patients
on
Medicaid
and
Medicare,
both
of
which
reimburse
hospitals
at
a
lower
rates
and
often
fail
to
cover
the
full
costs
of
providing
care,
MacDonald
added.
For
many
of
these
vulnerable
hospitals,
the
loss
of
the
ACA
tax
credits
isn’t
just
another
financial
hurdle
—
it’s
a
threat
to
service
lines
and,
in
some
cases,
their
long-term
viability,
she
stated.
“When
coverage
declines,
the
impact
shows
in
reduced
access
for
patients
and
diminished
capacity
in
the
healthcare
system.
Hospitals
facing
higher
levels
of
uncompensated
care
are
forced
to
make
difficult
choices
to
sustain
a
community’s
access
to
24/7
care,
whether
that’s
scaling
back
services
or
delaying
investments
that
improve
quality
and
access
for
patients,”
MacDonald
remarked.
She
also
noted
that
higher
rates
or
uncompensated
care
can
reduce
hospitals’
ability
to
offer
competitive
wages,
which
exacerbates
healthcare’s
workforce
crisis.
The
broader
economy
could
take
a
hit,
too
The
expiration
of
ACA
enhanced
subsidies
could
also
have
a
negative
effect
on
the
broader
economy.
Julio
Fuentes,
CEO
of
the
Florida
Hispanic
Chamber
of
Commerce,
warned
that
the
additional
healthcare
costs
from
the
credit’s
expiration
could
force
small
business
owners
to
make
“decisions
that
really
no
one
wants
to
make”
—
such
as
delaying
hiring,
raising
customer
prices
and
cutting
employee
hours.
Even
though
these
small
business
owners
don’t
sponsor
their
employees’
insurance,
they
often
cannot
afford
to
absorb
sudden
spikes
in
personal
healthcare
costs
without
cutting
hours
or
staff.
“This
is
a
main
street
crisis.
It’s
certainly
not
a
Wall
Street
problem,
by
no
means.
The
first
people
who
feel
this
pain
are
the
ones
who
keep
our
communities
running
—
you’re
talking
about
the
landscapers
with
five
employees,
the
woman
who
runs
a
small
cleaning
business,
the
contractor
who
depends
on
a
handful
of
subcontractors,”
he
explained.
Economists
estimate
that
allowing
ACA
tax
credits
to
expire
would
lead
to
about
286,000
job
losses,
as
well
as
reduce
the
country’s
GDP
by
$34
billion.
Those
estimates
come
from
the
Commonwealth
Fund
and
the
George
Washington
University
Milken
Institute
School
of
Public
Health.
Their
teams
first
calculated
how
much
federal
spending
on
enhanced
ACA
tax
credits
would
disappear
if
the
subsidies
expired
—
roughly
$26
billion
next
year
alone.
That
reduction
in
spending
affects
not
only
households
—
but
also
providers
and
payers,
who
would
see
lower
revenues
as
a
result
of
fewer
people
being
able
to
afford
coverage.
About
10%
of
Americans
are
employed
in
the
healthcare
sector
—
so
putting
financial
pressure
on
industry
will
inevitably
lead
to
a
wave
of
job
losses,
the
researchers
explained.
The
researchers
used
an
input-output
model
to
estimate
the
broader
effects
on
the
economy
—
accounting
for
direct
impacts,
like
providers
losing
income
and
laying
people
off,
and
indirect
effects,
such
as
decreased
lifestyle
spending
by
families.
Time
is
running
out
Some
lawmakers,
including
Senator
Bill
Cassidy
(R-Louisiana),
have
floated
the
idea
of
replacing
the
ACA
premium
tax
credits
with
other
mechanisms,
like
pre-funding
Health
Savings
Accounts
(HSAs).
They
are
curious
as
to
whether
directing
funds
straight
to
individuals
could
increase
efficiency
and
reduce
overhead.
“Is
there
anybody
who
would
not
want
to
take
a
large
portion
of
that,
which
we’re
using
to
help
Americans
purchase
healthcare,
and
give
it
directly
to
the
individual,
so
that
100%
of
its
used
to
purchase
healthcare,
as
opposed
to,
as
opposed
to
giving
that
money
to
the
insurance
company,
of
which
20%
goes
for
profit
and
overhead?”
Cassidy,
who
is
chair
of
the
Senate
Committee
on
Health,
Education,
Labor
and
Pensions,
as
during
a
Monday
hearing.
This
approach
would
be
impractical,
according
to
Lauren
Aronson,
executive
director
of
Keep
Americans
Covered.
She
pointed
out
that
this
could
cost
the
federal
government
more
than
simply
extending
the
tax
credits,
and
there
isn’t
enough
time
to
implement
a
whole
new
system.
“If
you
were
to
theoretically
pre-fund
an
HSA
that
would
very
likely
cost
more
federal
dollars
than
the
cost
of
extending
the
tax
credits
themselves.
You’d
have
to
pre-fund
between
$1,500
and
$6,000
per
year.
Then
thinking
about
it
operationally,
plans
would
have
to
then
refile
rates
and
put
new
high
deductible
health
plan
offerings
into
the
market
for
2026
—
there’s
no
time
to
do
that
between
now
and
January
1,”
Aronson
explained.
She
said
that
the
ACA’s
current
design
—
applying
credits
directly
to
monthly
premiums
—
is
essential
for
keeping
coverage
affordable
in
real
time
for
middle-class
families.
Senators
from
both
parties
are
forming
working
groups
to
address
the
issue,
but
there
hasn’t
yet
been
a
public
hearing
or
vote
on
extending
the
ACA
premium
tax
credits,
despite
the
looming
healthcare
affordability
crisis.
Aronson
emphasized
that
immediate
action
is
needed
to
prevent
the
crisis
from
occurring.
Photo:
krisanapong
detraphiphat,
Getty
Images