As the federal government enters its 3rd week of shutdown, health policy experts warn that millions of Americans could soon lose access to healthcare — a crisis that could unravel more than a decade of progress under the Affordable Care Act.
The potential lapse of enhanced ACA premium tax credits — originally expanded under the Biden Administration’s American Rescue Plan of 2021 — would send monthly premiums soaring and wipe out zero-dollar plans that now serve as a lifeline for low-income families.
The tax credits are set to expire at the end of December. But millions of Americans are receiving notices this month to renew their ACA plans for the following year. Many are experiencing monthly premiums that are double of what they currently pay. Open enrollment begins Nov. 1. Health care analysts predict at least 4 million people will immediately drop out of ACA plans — and lose health coverage entirely — because they cannot afford it.
Sticker Shock
“This would be the most significant rollback in coverage since the Affordable Care Act was passed,” said Anthony Wright, executive director of Families USA. “Every day closer to open enrollment means more people get sticker shock, fall off coverage, and we won’t be able to get them back,” he said at an Oct. 10 American Community Media news briefing. “There’s a real urgency for this that cannot wait until some fix that happens in January.”
Republicans have pushed back against continuing the enhanced premium tax credits, stating that undocumented immigrants are accessing health care. But all speakers at the Oct. 10 news briefing refuted this notion, noting that undocumented immigrants — including DACA recipients — are ineligible for any manner of federally-funded healthcare, including coverage through the ACA marketplace, as well as Medicaid.
Last summer, Congress passed the “One Big Beautiful Bill,” — HR 1 — now rebranded as the Working Families Tax Cut. HR 1 stripped $990 billion from the Medicaid budget and severely restricted access. Politicians on both sides of the aisle expressed concern about the hit to rural hospitals, which serve a disproportionately high number of Medicaid patients and already operate on razor-thin margins.
Rural Hospitals
In September, Congress amended HR 1 to add the Rural Health Transformation Program, which would dole out $10 billion per year over the next 5 years to qualifying rural hospitals. But Wright dismissed the funding as trivial. “When you compare $50 billion in temporary cuts versus $990 billion permanent cuts, it’s clear that it’s just a fig leaf that really actually does nothing to actually cover the severe cut to rural hospitals,” he said.
“If millions of people fall off coverage, it means fewer paying patients, more uncompensated care, and greater financial strain on hospitals. We’re not providing care at the front end. We’re paying for it in the most expensive, most inefficient way possible, which is at the emergency room on the back end,” said Wright.
Coverage Gains at Risk
Jennifer Sullivan, Director of Health Coverage Access and lead of the Beyond the Basics project at the Center on Budget and Policy Priorities, said the loss of ACA enhanced premium tax credits would hit hardest among families earning modest wages.
“Right now, 93% of marketplace enrollees get a premium tax credit,” she said. “Nearly half have incomes below twice the poverty level — about $32,000 a year. This is not a lot of money.”
Sullivan said the subsidies have driven historic gains in healthcare access, particularly among communities of color, who made up more than half of ACA enrollees nationwide in 2024. “We saw a 186% growth in coverage among Black people and a 158% growth among Latino people after these enhancements went into place,” she said.
But that progress could evaporate almost overnight. “People will be out of the game if they have to pay even a dollar,” Sullivan warned, citing research that suggests 400,000 people would immediately lose coverage if zero-premium plans disappeared. “We hear suggestions that people need to have skin in the game. But people will simply be out of the game if they have to pay.”
Sullivan also expressed concern for immigrant families who are eligible for benefits but fearful of accessing them amid anti-immigrant rhetoric. “We’re likely to see a large chill effect — a decline in people who are eligible for these benefits who don’t feel comfortable accessing them,” she said.
Americans Overwhelmed by Costs
For many Americans, healthcare affordability has already reached a breaking point.
“Just under half of U.S. adults say it’s difficult for them and their families to afford healthcare,” said Ashley Kirzinger, director of survey methodology and associate director of the Public Opinion and Survey Research Program at KFF. “1 in 4 say they’ve had problems paying medical bills in the past year — and that’s even with the enhanced premium tax credits,” she said, citing findings from a KFF poll released Oct. 3.
Kirzinger noted that awareness of the looming expiration remains dangerously low. “Only about 4 in 10 people have heard anything about it,” she said. “That means 6 in 10 of those who buy their own coverage — the very people who will be impacted — still haven’t heard much or anything at all.”
Bipartisan Support to Extend Tax Credits
Despite the lack of awareness, there is strong bipartisan support for extending the credits. “8 in 10 Americans support Congress extending these tax credits,” Kirzinger said. “That includes 92% of Democrats, 82% of independents, and even 59% of Republicans — including 57% of MAGA supporters.”
”People may dislike the ACA, but what they hate more than the ACA are high healthcare costs,” she said.
Without Congressional action, 7 in 10 people who buy their own coverage say they would no longer be able to afford it without seriously impacting their household budgets. 4 in 10 say they would go without coverage altogether, noted Kirzinger, citing KFF poll results.
Ripple Effects Throughout Healthcare System
The consequences would ripple far beyond individual households. “People without insurance are less likely to get preventive care and more likely to face stress about emergency healthcare services,” Kirzinger said. “We know what happens when people lose coverage — their health suffers.”
Sullivan added that when people delay care, the costs ultimately shift to everyone else. “When there are large numbers of uninsured folks who have to defer and delay care, they end up needing more urgent care that costs all of us when they eventually get the care they need,” she said. “That has long-term impacts on their health and well-being.”
All three experts said the harm is entirely preventable. “This is a choice,” Sullivan said. “We knew this problem was coming. We know what the solution is. And the sooner we act, the fewer people will be harmed.”
