I hope you all have been having a good week, and are still basking at least a little in the glow of Tuesday’s election results. I know there will be more bad days ahead, but I don’t think I realized how much I needed just a little hope that there is a light at the end of this very dark tunnel.
I’ve been quiet this week in part because I’ve been attending the annual meeting of the American Public Health Association, in Washington D.C. this year. When the conference was planned, no one was expecting that the government would be shut down. Our event at the National Museum of African American History and Culture? Cancelled, because the Smithsonian is closed. Our opportunity to visit colleagues working in HHS, and talk about strategies to improve the public’s health? Gone, unless they happened to be around and wanted to get together for a meal on personal time. Downtown DC was a ghost town. It was easy to get a restaurant reservation, but my Lyft driver on the way to the airport was telling me he was concerned about making his rent this month because there just weren’t enough fares with the city so quiet.
As I noted on Oct 29, this shutdown is really a fight over health insurance. Specifically, it’s a fight about whether the 24 million people who purchase their health insurance through the Affordable Care Act (ACA) exchange in their state will still be able to benefit from “enhanced subsidies” to make their premiums affordable.
Let’s break this down. When the ACA was first introduced, people were expected to pay premiums that were at most between 2% to 10% of their income. The poorest people needed to pay 2% of their income, and the rest would be subsidized by the government. People who made more money would need to pay up to 10% of their income for health insurance, and if it cost more than that, the rest would be covered by government subsidies.
The problem is, this was still a big barrier for a lot of people. To qualify for the lowest percentage of income (aka the biggest subsidy) you’d have to make between 100-150% of the Federal Poverty Level, or FPL. In 2025, the Federal Poverty Level (FPL) for a family of 4 is $32,150 a year. For individuals, it’s $15,650 a year. So let’s say you’re a family of 4, making 150% of the FPL—that means your family has $48,225 of income to pay for a year’s worth of rent, car (including gas), food for four people, taxes, and any other household expenses, plus health insurance. With the subsidy, you’d pay 2% of your income, which is just shy of $1000 a year. That may not seem like much, but $1000 is a lot of money for someone who’s needing to be creative after rent’s been paid to buy enough food so that four people don’t go to bed hungry.
It’s even worse for the “middle income” folks—let’s say a family of 4 was making just shy of 300% of the FPL. In 2025, that’s $96,450. That might sound like a great salary, though if that’s the combined salary between two adults and they live in a fairly expensive area, that can still go quickly. People making that much would have to pay 7.5% of their income, or $7,234 a year, on health insurance. That’s a lot of money—so much money that a lot of people simply didn’t participate, because they felt like they couldn’t afford it.
So, in 2021, Congress passed “enhanced” subsidies that lowered the affordability thresholds from 2 to 10% to be 0 to 8.5% instead. This meant a family of 4 making $96,440 a year would have to spend only 6% of their income, or $5,787. Still a lot, but that’s a few thousand dollars left to save, or more easily cover the family’s needs. But the bigger difference was for the poorer folks: a family of 4 with an annual household income below $48,225 a year could now get health insurance for free, and the government would pay for it using our tax dollars.
Since the enhanced subsidies were put into place, the number of people who enrolled in health insurance through the market went from only 11 million people (in 2020) to 25 million (in 2025). That’s 14 million more people with insurance to cover the health care they need! Plus, when a few million of those people don’t have to receive and pay a health insurance bill every month, that reduces strain on the system. (And if Republicans are so keen on reducing the federal workforce, then we’ll need to implement a lot of changes that reduce strain on the system.)
The One Big Beautiful Bill Act eliminated these enhanced subsidies, and thus they’re set to expire on December 1 unless something is done to change this. That’s why people are seeing dramatically higher costs if they’re looking at plans available to them on their state’s exchange during the open enrollment period that started November 1. The New York Times has some nice tables and other visuals (like interesting maps) that help illustrate what these changes will mean starting December 1. The Congressional Budget Office has estimated that if the enhanced subsidies go away, 3.8 million fewer people in the U.S. will have health insurance, either because they don’t enroll in the first place, or because they lose health insurance when they can’t pay their bills.
When people don’t have health insurance, a lot of bad things happen:
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They tend to avoid going to the doctor for care until something becomes unavoidable, and which point it’s often an emergency—much more expensive and debilitating, when it could have been dealt with more easily at an earlier stage. They’ll be more likely to die, or more likely to deal with lifelong disabilities or lengthy recovery times, which also impacts their ability to work and care for other family members.
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As it is, 100 million Americans are carrying medical debt, and more than half a million Americans every year file for personal bankruptcy because of crushing medical bills. These statistics will only get worse if the ACA enhanced subsidies expire, because people without insurance (or who feel the need to purchase cheaper insurance that has worse coverage) will have to pay a lot more out of pocket.
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Especially with cuts to Medicaid on top of rising premium costs for people purchasing insurance through the ACA exchange, we can expect a lot more people to use the emergency room for healthcare, rather than seeing a regular doctor when the problem was less severe. This means that if YOU have a health emergency, the wait may be longer for you to be seen, even if you have excellent health insurance.
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Public hospitals are legally obligated to provide a certain level of care, particularly emergency care, regardless of a patient’s ability to pay. When they provide care that the patient can’t pay for (and they don’t have insurance or insurance doesn’t cover it), this is called “uncompensated care.” When hospitals provide high rates of uncompensated care, this has two effects: (1) costs are sometimes shifted to people who do have insurance, through rising costs of procedures billed to private insurance (which comes with co-insurance or high deductibles for many people), and (2) health clinics and hospitals can face serious financial instability, sometimes even risking closure. This could mean that people in more rural areas will have to travel farther for care, including in an emergency, because their regional center closed.
Bottom line, Democrats are currently refusing to agree to a budget that doesn’t restore the ACA’s enhanced subsidies. Republicans are saying they won’t negotiate on health insurance subsidies while the government is closed, so Democrats need to agree to the budget and re-open the government, and then they’ll come to the table and try to figure it out.
I’ll let you decide whether that’s a deal that Democrats should take. I for one don’t trust that if Democrats compromised and passed the budget, Republicans would then follow through and negotiate in good faith to solve the health insurance woes of millions of Americans. I’m glad to see Democrats standing firm, no matter how inconvenient it is for all of us. Next time you hear someone say that it’s Democrats keeping the government shut down, remind them it takes two to tango.