Unless Congress acts, millions of Americans will have to choose between paying rising health insurance premiums or going without insurance by 2026.
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Dawn Wheeler followed every twist and turn of the government shutdown. In some ways, she said, she felt like her life was in danger.
The 59-year-old Edwardsville, Kan., resident is one of the millions of Americans who buy health insurance through the Affordable Care Act’s Marketplace, and his premiums could rise next year unless Congress extends the COVID-19 era ACA tax credits.
Democratic lawmakers had called for an extension of Obamacare subsidies to be included in the spending plan to reopen the government. But eight Senate Democrats relented to those demands and on November 10 voted with Republicans to end a record 43-day government shutdown. Shortly after, the compromise was passed by the House of Representatives and President Donald Trump signed it into law without the health care bill.
more: The ACA health insurance tax credit could end in December. How will it affect you?
Now, patient advocates say they face a bumpy road to getting the subsidies passed by the end of the year, when premiums could more than double.
Senate Minority Leader John Thune (R.S.D.) has promised a vote in December on a plan to extend Obamacare subsidies that help millions of Americans access health care. But Republican House Speaker Mike Johnson said he would not take a similar vote on the floor.
“If we weren’t able to accomplish that during the shutdown stalemate, it’s hard to think about what we would transition now,” said Rebecca Karch, executive vice president of policy and programs at the National Patient Advocacy Foundation.
For Wheeler, who has metastatic breast cancer, Congress’ final decision means a difference of tens of thousands of dollars. Without the subsidy, her premiums would jump from $272 a month to $2,335 a month, or about 60% of her family’s income, she said. She is currently unemployed due to treatment and relies on her husband’s income.
She can’t afford to lose her insurance. One of her chemotherapy drugs costs $20,000 a month, and Wheeler typically reaches her out-of-pocket maximum by the end of January each year.
Wheeler said he was initially angry with Democrats for negotiating an agreement to end the government shutdown that did not include the ACA measures.
“I really wish the Democrats had held out,” Wheeler said of the government shutdown. “We’ll have to see how this goes, but I still feel like I’m dangling my foot over the fire.”
Ultimately, she said, she blames Republicans for not addressing the issue in the spending package passed in July.
“We’re real people with real lives and real families,” Wheeler added. “My mortgage is going up because of property taxes. My utility bills are going up, and food prices are going up. Everything, the cost of living is going up across the board. I don’t know what to do.”
Obamacare market users are at a loss
Congress originally created the enhanced tax credit in 2021 to help Americans afford health insurance during the COVID-19 pandemic.
According to an analysis by the health policy group KFF, the plan would expand the eligibility for ACA plans to up to four times the federal poverty level (about $63,000 for a single income earner today). It also reduced the percentage of income that subsidized participants had to pay for premiums.
The enhanced subsidies have more than doubled the number of people enrolling in ACA plans over the past five years, with the majority coming from red states such as North Carolina, Florida, Georgia and Texas, according to KFF.
The group estimates that up to 22 million Americans with ACA plans could see their monthly health insurance premiums jump 114% if the tax credits expire, and many could lose coverage.
The Congressional Budget Office estimated that approximately 4 million people would be uninsured without the ACA tax credit extension. If passed, the subsidies would increase the federal deficit by about $350 billion by 2035, according to the agency.
Sabrina Corlett, co-director of Georgetown University’s Center on Health Insurance Reform, said the price hikes are being driven by several different factors. If subsidies are not expanded, people will have to pay a higher percentage of their health insurance premiums.
At the same time, insurers in the ACA market are raising premiums because they expect more people to drop their insurance coverage as a result of sticker shock from the ACA cuts. Fewer people paying into the scheme, especially healthy people, means costs are spread over a smaller pool and prices rise.
The Congressional Budget Office estimated that approximately 4 million people would be uninsured without the ACA tax credit extension. If passed, the subsidies would increase the federal deficit by about $350 billion by 2035, according to the agency.
“That’s why they’re introducing total premiums that are on average 20% to 30% higher than they would otherwise be,” Corlett said. “This is a severe economic blow to millions of American families.”
Others, including Robert Kastner, a research professor at the University of Chicago Harris School of Public Policy, say the partisan debate over stronger tax credits has led to exaggerated claims.
Kaestner believes estimates that more than 4 million Americans will lose health insurance are exaggerated. He put the number at about 2 million people, but said this was still a significant cost and said there would be downsides no matter what happens.
He said ending the expanded subsidies would leave people without health insurance, but Kaestner also argued that it would target government spending to the poorest Americans.
“From 2020 to today, Medicaid and ACA marketplaces have grown by 20 million people, which means an additional 20 million people are receiving federal subsidies for health insurance,” Kaestner said. “If you look at what the uninsured rate is, there’s no evidence that 20 million people came from the uninsured population. So we can’t be sure about this, but a lot of those 20 million people are from private insurance.”
Who will be affected by the loss of subsidy?
Of the 24.3 million Americans insured through ACA plans, about 22 million, or about 92%, receive some type of subsidy.
According to KFF, small business owners and people working for small businesses that do not offer employer-sponsored health insurance make up the majority of users of the ACA marketplace.
Those include farmers, real estate agents, restaurant workers, retail workers and people working in gig jobs, said Anthony Wright, executive director of the health care advocacy group Families USA.
Wright said that because the ACA extension is no longer tied to shutdown fights, the path to getting it through Congress before higher premiums takes effect is “less visible.” Open enrollment begins Nov. 1, and those who log into the ACA Marketplace are already being hit with steep fees.
Wright could not criticize Democrats for abandoning the ACA requirements in the government shutdown fight, instead criticizing Republicans for not including the bill in the One Big Beautiful Bill Act.
“There’s no question this was a setback,” Wright said. “This should be the simplest vote in the world to prevent huge premium increases after the affordability election.”
But some voters who rely on tax credits say they are dissatisfied with Democrats. A CBS News poll released on November 16 found that 55% of Americans believe Republicans got more of what they wanted from the government shutdown negotiations. A majority of Democrats said their party had conceded too much.
Eric Kurland, 61, and his wife Kari Kurland, 63, purchased ACA coverage after 2021, when subsidies made it more affordable. Now retired, they taught for many years in Scottsdale, Arizona.
In 2025, they paid $513 per month for ACA insurance. For 2026, Eric Kurland said the cheapest plan available for the same coverage level would cost $2,218.69 per month, or just over $26,000 for the year. Their combined income is about $80,000 a year.
Kurland said she is choosing not to get ACA coverage without the subsidy, but she has another option: getting health insurance through her state’s retirement system. Kurland estimates it costs about $1,000 a month, which equates to about 8 percent of his annual income.
“This is a solution to some extent, and we’re going to cut back a little bit,” Kurland said. “I feel like the Democrats have given up the fight and they think they need to fight and I’m angry at them.”
The future of tax credits is uncertain
In a Nov. 18 Truth Social post, President Trump told Congressional Republicans not to “waste their time” considering extending the enhanced ACA tax credits. The president has said he would only approve measures that send money “directly to the people,” but it is unclear how such a plan would work.
Sen. Bill Cassidy (R-Louisiana) has floated a proposal to replace the ACA’s premium tax credits with prepaid health savings accounts funded in part by money from expired tax credits, in line with President Trump’s preferred approach. Those who sign up for a Bronze plan, one of the lower premium and higher deductible coverage tiers on the market, will receive money in their HSA account.
Cassidy, a physician, suggested in a Nov. 16 interview with CBS News that Republicans would work out the details of the plan and vote against Democrats’ proposal to extend ACA enhanced subsidies by mid-December.
However, the two parties remain deadlocked for now, with only three weeks remaining in Congress this year.
As the clock ticks down, Families USA’s Wright said some people are already starting to make final medical decisions for next year. The ACA open enrollment period runs from November 1st to January 15th.
“Every time we fall behind, these high premium rates become entrenched and more people are shocked by these rising premiums and plan to lose their insurance,” Wright said. “Every time we delay, there is further damage to both individual families and our system.”
USA TODAY Nation Desk reporter Carissa Waddick can be reached at kwaddick@usatoday.com.
Contributors: Sarah Wire and Ken Alltucker, USA TODAY
