When Americans decide something is right, political inertia does not prevent us from acting, and now is the time for health care. Before the Affordable Care Act (ACA), 60 percent of Americans had employer-sponsored coverage, 20 percent relied on public programs, and the remaining 20 percent had to obtain insurance on their own, a difficult task because the individual market was unsustainable. But the ACA stabilized these issues by expanding Medicaid eligibility, eliminating adverse selection in the individual markets, requiring near-universal participation, and subsidizing insurance premiums.

These changes stabilized markets and expanded coverage to about 20 million Americans by 2016, creating access to outpatient and preventive care. Despite the ACA’s popularity, its future remained uncertain, facing repeal efforts that peaked after 2016 but failed with Senator John McCain’s decisive vote. This reflects status quo bias and loss aversion. Once Americans receive a benefit, they work to keep it. This dynamic explains why programs like Social Security, Medicare, and ACA subsidies become politically durable over time.

In 2021, the American Rescue Plan increased ACA subsidies, lowering affordability thresholds to 0-8.5 percent of income, expanding cost-sharing reductions, and increasing insurance accessibility. Although initially temporary, the subsidies were extended, further increasing ACA enrollment to an estimated 24 million enrollees in 2025. While these measures improved access, their temporary status and high federal cost remain controversial, as they are set to expire at the end of 2025. Repealing ACA subsidies will likely increase the number of uninsured people. Emergency departments will likely provide more uncompensated care and treat more patients with preventable conditions when primary and outpatient care are accessible.

Political considerations

While the recent government shutdown had multiple causes, extending ACA subsidies became the key reason the Democratic Party withheld support to cross the 60-vote Senate threshold. A president can influence public opinion and issue executive orders, but only Congress can appropriate funds.

This is consistent with the federal government’s design. Jean-Jacques Rousseau, in The Social Contract, argues that the authority to make laws must lie with representatives of the communities the people reside in, since being part of those communities will ensure they are accountable to the communities they represent. He further clarifies that the rulers, who enforce the law, are too removed from individuals and their concerns and cannot balance what is best for the population from what is best for the ruler. He clarifies that rulers must not make laws, because combining these powers replaces the people’s will with the rulers. Similarly, James Madison, in Federalist No. 47, echoed these beliefs, calling the union of legislative and executive authority “the very definition of tyranny.”

The founders of the United States were influenced by these and other political philosophers. As a result, the U.S. Constitution requires Congress, not the executive, to make laws, especially regarding financial appropriations. The founders believed the executive was too removed from community needs, while Congress members were more accountable to citizens through frequent elections and local representation.

Presidents receive more public attention and generate media talking points to resolve policy disputes. However, the people’s sovereignty resides with their congressional representatives. This is evident in the debate over the ACA subsidy. Advocacy efforts should target key congressional members, especially those in swing districts and on budget committees.

The path ahead and recommendations for action

Congress will decide whether to extend ACA subsidies, let them expire, or create a temporary fix until political sentiment changes. Some may believe the strong partisan divide and the ACA’s politicization make repeal inevitable. However, narrow majorities make repeal difficult. Representatives in competitive districts or areas reliant on ACA subsidies are especially vulnerable. I believe the ACA will persist. Perhaps subsidies will be extended temporarily. But even if they are repealed, providers must work to restore them.

Physicians and other health care providers have a role to play, such as:

• Sharing stories of how the ACA impacted your patients for good.
• Advocating with Congress members either directly or through professional society advocacy campaigns.
• Write op-eds or use professional social media to explain why subsidies matter for all forms of health care.
• Collaborating: Work with hospital leadership and other specialties to present and advocate for access to care at all payment levels.
• Patient outreach: Ensure that health care systems provide access to outpatient care resources.

Establishing effective policy takes time. In 1935, Social Security provided a basic income, lifting 30 percent of elderly Americans out of poverty. Thirty years later, Medicare protected this group from catastrophic health costs, resulting in more secure retirements. Sixty years after Medicare, the ACA offers greater financial and health security for working-age people at risk of poverty. While the ACA faces challenges, strong public support and congressional advocacy can help it overcome barriers, as Social Security and Medicare did. Since it is the right thing to do, isn’t the ACA destined to become politically durable? I believe, as Americans, we will do what’s necessary to move our country closer to providing all of our citizens access to quality health care. But we need to act, and now is a great time.

Curt Dill is an emergency physician.