Just over 40 days into the longest government shutdown in American history, the rope snapped. The enhanced premium tax credits that kept 22 million Americans insured will expire on December 31, 2025. Premiums are soaring, protections are vanishing, and the safety net is unraveling. Americans are already reeling from gutted SNAP benefits. Now they’re losing health care coverage too. The Congress has made it clear that the most vulnerable are not only expendable, but also forgettable.
We’re surgeons who have spent years navigating federal bureaucracy, analyzing health policy, and advocating for patients who fall through the cracks. Doctors for America represents thousands of clinicians who believe health care is a human right, not a luxury. We know the data: insurance coverage saves lives, improves outcomes, and actually reduces long-term health care costs. The ACA’s enhanced subsidies were a lifeline, not just for patients, but for those of us trying to practice medicine in communities where the nearest hospital is 50 miles away and half our patients are uninsured. The repercussions of ACA subsidies expiration are multifaceted, affecting the patients, physicians, and health care systems at large.
An estimated 4 million Americans will lose their marketplace coverage overnight and become uninsured. According to the Kaiser Family Foundation, premiums for ACA marketplace plans will surge by 18 percent in 2026 when the subsidies expire. Enrollees with incomes above 400 percent of poverty will experience a larger increase in payments. A 60-year-old couple earning $85,000 could see their annual premium jump by 440 percent, from $602 per month to $2,652 per month. [Image of chart comparing ACA premiums with and without enhanced subsidies] A 45-year-old making $20,000 could go from paying nothing to $420 per month. According to the Century Foundation, rural enrollees will see their out-of-pocket costs more than double (a 107 percent increase), deepening the geographic and economic divide that already makes health care a luxury in small-town America.
According to Covered California, premiums will spike by 76 percent for Latino enrollees, 71 percent for Asian Americans, and 67 percent for Black Americans. These are the same communities already devastated by SNAP cuts, already working multiple jobs without benefits, already one medical emergency away from bankruptcy. The enhanced subsidies weren’t perfect, but they were a start; a down payment on addressing decades of structural inequity.
The Urban Institute projects a devastating $32.1 billion revenue loss for health care providers in 2026 alone, with a $7.7 billion spike in uncompensated care. Hospitals in Texas and Florida, states that refused Medicaid expansion, will hemorrhage resources. Pharmacies and physician practices will be forced to cut services or close altogether, threatening care in communities already on the edge.
Here’s what galls us: This didn’t have to happen. The enhanced credits allowed households with incomes above 400 percent of the federal poverty level to qualify for subsidies, giving middle-income families their first real shot at affordable coverage. Enrollment hit record highs. The uninsured rate dropped to historic lows. [Image of graph showing U.S. uninsured rate trends] We built this system to be a lifeline in hard times, just for it to crash in a few years.
When coverage disappears, patients don’t vanish. They just show up sicker. Emergency departments will overflow with preventable conditions. Community health centers will buckle under uncompensated care. Physicians like us will keep taking the same oath while being forced to ration care based on zip codes and bank balances.
We’ve worked in federal policy long enough to know how the game is played. But we also work in trauma bays, operating rooms, and clinics, where the consequences of political cowardice show up with vitals and ventilators. Examples include the patient who stops showing up for a traumatic brain injury follow-ups because their deductible tripled, the parents sitting in the office trying not to cry because they have to choose between providing food to the family and keeping their coverage, and the millions of people rationing insulin and skipping cancer screenings because the Republicans and Democrats decided they were acceptable losses. These aren’t hypotheticals. They’re our Tuesdays.
The shift from preventative care to reactive care will be inevitable. Health care systems should brace themselves to see a surge in emergency department visits for heart failures that went untreated, cancers that were diagnosed too late, and infections that progressed due to lack of means to afford antibiotics. Patients with chronic diseases like diabetes, hypertension, and mental health conditions will suffer first and suffer the longest because routine labs and follow-ups will be unaffordable luxuries. Missed vaccinations, cancer screenings, and preventative visits will shake the foundation of public health. Instability in coverage will lead to instability in health and increase in human suffering.
The rope isn’t slipping anymore, Congress. You already let go. The patients are going to pay the price first. Then, the entire health care system, including those of us on the frontlines, will pay it next.
Sandya Venugopal is a neurosurgeon. Tina Bharani is a clinical fellow in minimally invasive and bariatric surgery.
