WASHINGTON – Ellen Allen, 64, pays $497 each month for health care through the Affordable Care Act Marketplace. If the Senate doesn’t act by Tuesday, Allen’s monthly premium could skyrocket to $2,800.
“It’s going to take over half of my take-home pay,” Allen said. “Nobody should have that kind of financial strain just to have access to health care.”
Since 2023, Allen has directed West Virginians for Affordable Health Care, a nonprofit aimed at preserving Medicaid funding and educating the state’s residents about health care issues.
In addition, Allen herself benefits from $1,800 each month in enhanced premium tax credits, which allow her insurance company to lower her premium.
First introduced in the 2021 COVID-19 relief package, the enhanced credits expanded eligibility for discounts on ACA — or Obamacare — plans. Democrats argue these enhanced subsidies make health care more affordable for middle-income families.
These subsidies are the lightning rod at the center of congressional Republicans’ and Democrats’ negotiations to avert a government shutdown.
Senate Republicans introduced a bill to fund the government through Nov. 21, which would extend government funding at current levels and increase security funding for lawmakers. Democrats’ proposal would fund the government through Oct. 31, permanently extend the ACA subsidies and reverse nearly $1 trillion in Medicaid cuts in the Big Beautiful Bill.
Democrats’ refusal to vote for any stopgap funding bill that does not extend these subsidies, Republicans argue, will catapult the U.S. into its first shutdown in six years.
Republicans have expressed willingness to negotiate on whether to extend the subsidies before they expire at the end of the year. However, Democrats insist the issue must be addressed sooner, before Americans begin to enroll in plans for 2026.
“This is a matter to be dealt with right now, not at the end of the year,” House Minority Leader Hakeem Jeffries (D-N.Y.) said at a Friday press conference.
On Wednesday, enrollees will begin receiving renewal notices revealing their premium quotes for next year. Most states begin open enrollment on Nov. 1.
If Congress waits until after Oct. 1 to extend subsidies, uncertain insurers could begin jacking up premiums to account for increased risk, according to Timothy Jost, professor emeritus at the Washington and Lee University School of Law.
“When Republican leadership in Congress says, ‘Oh, we’ll look at this later on in the year,’ it’s just too late,” Jost said.
With the fiscal year ending Tuesday, the onus falls on the Senate to reconsider the beleaguered bills and avert a government shutdown.
Jeffries has adopted the slogan “Cancel the cuts, lower the costs, save health care” in recent days to reflect Democrats’ demands.
On Friday, House Minority Leader Hakeem Jeffries (D-N.Y.) decried President Donald Trump’s decision to cancel a previously scheduled meeting to discuss the potential shutdown. Trump eventually met with Jeffries and Senate Minority Leader Chuck Schumer (D-N.Y.) on Monday, but they left without a deal. (Isaiah Steinberg/MNS)
Millions of Americans like Allen are caught in the crossfire of the standoff, uncertain whether their premiums will spike as they prepare to select plans.
Holding the government ‘hostage’
For Republicans, however, the Democrats’ refusal to negotiate is reckless.
“It is irresponsible for Democrats to now hold the American people hostage over a program expiring on the very timeline they established,” Rep. Nathaniel Moran (R-Texas) told Medill News Service in a statement.
Twenty-four million Americans are enrolled in federal and state ACA marketplaces, and many of them receive enhanced premium tax credits, according to forthcoming Kaiser Family Foundation research.
“The Marketplace is becoming a more and more important source of coverage for folks who cannot get other sources of coverage,” said Jared Ortaliza, a policy analyst for the KFF’s Program on the ACA.
Enrollment in the marketplaces has more than doubled since 2020.
If the enhanced subsidies expire, Americans who receive them will see their premiums spike by more than 75% on average, and 4.2 million Americans could become uninsured by 2034.
While Senate Majority Leader John Thune (R-S.D.) acknowledged the impending open enrollment deadline, he told NBC’s Meet the Press on Sunday that the enhanced subsidies were “fraught with waste, fraud, and abuse.”
Republicans have repeatedly claimed that wealthy Americans have abused the enhanced subsidies, which Democrats dispute, since eligibility is based on the percentage of household income spent on health insurance.
The Centers for Medicare and Medicaid Services finalized a new rule in June aimed at reducing “improper enrollments” by tightening enrollment processes.
Voters overwhelmingly support extending the enhanced subsidies. A June KFF poll found that 77% of Americans, including 63% of Republicans, support extending the credits past this year.
The polling elucidates a shift in Republicans’ opinion toward the ACA.
Republicans have since abandoned full-scale repeal efforts, seeking instead to reform the law as enrollment rates increase among their constituents. Since 2020, 88% of new ACA Marketplace growth has been in states Trump carried in 2024.
Allen lives in the rural town of Pinch, 9 miles outside West Virginia’s capital, Charleston. The state has been a Republican stronghold for a quarter century. Marketplace enrollment in West Virginia jumped 235% in the past five years, third behind only Texas and Mississippi.
Effects on insurers, hospitals
As Republicans continue to portray Democrats’ strategy as reckless, Democrats are betting health care will be a winning issue in next year’s midterms.
Hospitals warn they could lose billions in revenue, and experts caution higher costs will drive healthier people out of the market, worsening the risk pool.
“The reality and the data and what people need seems pretty disconnected from the policy actions and politics of the national level,” said Purva Rawal, former chief strategy officer for the CMS Innovation Center.
Alexa McKinley Abel, director of government affairs and policy for the National Rural Health Association, explained that rural hospitals rely more than their urban counterparts on Medicare and Medicaid. If the subsidies lapse, she said, uncompensated care could increase and hospitals could shutter.
“People who aren’t able to transition to another source of coverage are going to be uninsured, and if they need emergency care, they’re going to continue to use their rural hospitals, but everyone else will be paying for it,” Abel said.
A spokesperson for Centene, one of the largest providers of ACA-compliant plans, told Medill News Service in a statement that the company could be forced to increase rates as they grapple with lower reimbursement rates, if the subsidies are not renewed before Nov. 1.
“Without swift action from Congress to extend the enhanced tax credits, families across the country will be forced to make the impossible choice between health care and other basic needs, risking a rise in the uninsured rate and the peace of mind that comes with coverage,” the spokesperson wrote.
In the past few weeks, the subsidies have been thrust into the political spotlight as Jeffries, Johnson and Thune have engaged in a media and advertising blitz to blame the other side for a shutdown.
None of that changes the situation on the ground for Allen and the roughly 62,000 West Virginians who rely on the enhanced subsidies — many of whom could lose health insurance in three months.
“This really shouldn’t be a political issue, because independents, Republicans and Democrats will lose their health care,” Allen said.
