Congress Goes Home and Millions Face Higher Health Care Costs
As Congress departs Washington without voting to extend the Affordable Care Act (ACA) marketplace premium subsidies, millions of Americans are heading toward a preventable affordability cliff.
In the U.S. healthcare system, patients are expected to be prepared, even when policymakers are not.
By not voting to extend Affordable Care Act (ACA) marketplace premium subsidies, millions of Americans are once again being told, implicitly, to figure it out on their own. The enhanced subsidies that make coverage affordable for many are set to expire, not because the system can absorb the shock, but because Congress chose not to act.
More than 22 million people currently rely on ACA marketplace coverage. The vast majority receive premium tax credits that make their insurance affordable. Without congressional action, those enhanced subsidies will expire, not because of market forces or system failure, but because Congress chose not to act.
Who relies on ACA marketplace coverage?
ACA plans are not a niche product. They cover people who are essential to the economy but poorly served by employer-based insurance. They are people navigating a system built around employment-based insurance in an economy that increasingly isn’t. This may be you, are your family members, and neighbors. They are:
People between jobs or starting new ones
Self-employed workers, freelancers, and gig workers
Employees of small businesses that do not offer health insurance
Early retirees not yet eligible for Medicare
Middle-income families who earn too much for Medicaid but cannot afford full-price premiums
These are working Americans navigating transitions, not people opting out of responsibility.
Consider this. Employer based coverage comes with built in tax advantages. Employees usually pay premiums pre tax, and employers receive tax deductions. People who must buy insurance on their own get neither benefit. ACA subsidies are designed to help level that playing field, yet this is often left out of the policy debate.
What happens when the subsidies disappear?
If Congress does not extend the subsidies:
Premiums will double on average for people receiving assistance
Many families will face hundreds to thousands of dollars more per year in premiums
Older adults, people in rural areas and those in "red" states will see some of the steepest increases
Multiple analyses project that millions of people could lose coverage as a result. Some will drop insurance entirely. Others will keep coverage but cut back on care.
But losing insurance is only part of the story. When healthcare becomes unaffordable, patients don’t just lose coverage, they lose options. They delay care. They ration medications. They skip follow-ups. Preventive care becomes a luxury, and chronic disease management becomes a constant risk calculation.
These are not theoretical harms. They are predictable outcomes in a system where affordability determines access.
Healthcare in the United States is already unaffordable for many. Allowing these subsidies to expire will make it worse. This is preventable.
Why preparation matters more than ever
One of the central truths of my upcoming book, The Prepared Patient is that the U.S. healthcare system does not reliably protect people, especially during moments of transition. Patients are expected to understand insurance rules, anticipate policy changes, compare plans, manage costs, and advocate for themselves, often while sick or under financial stress.
Congress’s inaction reinforces that reality.
When coverage becomes unstable, preparation becomes essential:
Understanding your insurance options
Knowing when and how to enroll
Anticipating cost changes before they become crises
Finding lower-cost and free care options
Planning for medication access and continuity of care
This was a choice
Congress had options. It had time. And it had clear evidence of the consequences. Leaving Washington without addressing the ACA subsidy cliff is not a neutral act; it is a policy decision with real-world consequences for patients, families, clinicians, and health systems.
The ACA marketplace subsidies made the system more survivable for millions of people. Allowing them to expire pushes patients back into a familiar position: navigating risk alone.
Until policymakers choose stability, patients will need preparation. Whatever people think about health insurance, not passing a stop-gap measure while making need changes doesn't make people "healthy again".
When lawmakers return, millions of Americans will be watching, and budgeting, to see whether affordable healthcare remains within reach.
The Prepared Patient: Your Guide to Surviving the Health Care System to be released in 2026 by Johns Hopkins University Press