TYLER, Texas (AP) — Celia Monreal worries every day about the loss of cartilage in her husband’s knees. Not only because it’s challenging for her to see him in pain, but also because she knows her healthcare costs could soon skyrocket.
Monreal, 47, and her husband Jorge, 57, rely on the Affordable Care Act marketplace for health insurance. If Congress does not extend certain ACA tax credits that are expiring at the end of the year, the cost of the fully subsidized plan will rise, putting it out of reach. Without insurance, they can’t afford the knee surgeries they expect, let alone the treatment they need for other problems like their chronic high blood pressure and high cholesterol.
“It worries me sometimes because when you’re not healthy, you’re not there for your kids,” Monreal said. “It’s a tough decision because, okay, do I spend $500 on a doctor’s visit or do I buy groceries?”
These are the decisions facing millions of Americans whose state and federal health insurance plans are up for renewal in November. The expanded premium tax credits, which have made coverage more affordable for low- and middle-income enrollees over the past four years, are set to expire this year unless Congress extends them. That will be, on average, more than double what subsidized students are currently paying in premiums next year, according to an analysis by nonprofit health research organization KFF.
The tax credits are at the heart of the government shutdown, which is now in its third week and has no end in sight. Democrats have called for the subsidies to be extended as part of any funding deal they sign, while Republicans say they will not negotiate the issue until the government is funded.
With Congress deadlocked and the Nov. 1 enrollment deadline for ACA plans approaching in most states, Americans like Monreal are left grappling with the unknown.
No extension would mean higher premiums for millions
More than 24 million people have ACA health insurance, a group that includes farmers, ranchers, petite business owners and other self-employed people who have no other options for health insurance because of their jobs.
The increased premium tax credits set to expire this year have made the cost far more bearable for many of them, allowing some lower-income enrollees to get health insurance without premiums and higher earners paying just 8.5% of their income.
When the tax credits expire, annual out-of-pocket premiums are estimated to rise by 114% — an average of $1,016 — next year, according to the KFF analysis.
While some premium tax credits will remain, the level of assistance will decrease for most participants. Anyone earning more than 400% of the poverty level — or about $63,000 a year for an individual — is not eligible for the remaining tax credits.
As a result, the hardest hit groups will include a petite number of higher earners who will have to pay much more without the additional subsidies, and a huge number of low earners who will have to pay a petite amount more, said Cynthia Cox, vice president and director of the ACA program at KFF.
With higher premiums, some people would drop out of health insurance altogether, Cox said. When many younger, healthier people inevitably go without coverage, insurance companies escalate costs for members of the insured population to reflect the fact that they are getting older and sicker.
The change could also strain hospitals as more uninsured people need emergency care they can’t afford. This could lead to hospital closures or cost increases.
“If there are fewer subsidies for people to get health insurance, there will be less health insurance and less health care,” said Jason Levitis, a senior fellow in the health policy department at the Urban Institute. “People are getting sicker and dying more often.”
A nurse prepares for the worst. A filmmaker is thinking about a modern job
Erin Jackson-Hill has allergies, asthma and piercing hip pain, which she manages with prescribed medication until she can have a hip replacement. But even with all of those conditions, the 56-year-old from Anchorage, Alaska, doesn’t think she’ll be able to pay for her health insurance next year if ACA subsidies aren’t extended.
The executive director of two nonprofits, who also cares for her 89-year-old father full-time, already pays nearly $500 a month for her premiums. If the subsidies go away, she wants to forego health insurance and pay for her asthma and allergy medication out of her own pocket.
Jackson-Hill said she worries about what would happen if her hip worsened and she couldn’t climb the stairs in her father’s two-story home without treatment.
“I have to go to the emergency room or I have to go broke to pay for it,” she said.
Another ACA participant, freelance filmmaker and associate professor Stan Clawson of Salt Lake City, said he will find a way to pay for his health insurance next year — even if it means buying cheaper groceries or getting a modern job that makes it possible.
Clawson, 49, has suffered from paralysis below his stomach since he fell while climbing at age 20. He is vigorous and generally vigorous, but his spinal cord injury has caused tendonitis in his shoulders and repeated urinary tract infections.
He also has to buy catheters that he can apply every time he urinates – the cost, he says, would be around $1,400 a month without insurance.
“I don’t think many people realize how expensive disability is,” Clawson said, adding that trying to live without health insurance would be “financially devastating.”
Chrissy Meehan, a hairdresser in Upper Chichester, Pennsylvania, has a neck condition that may require surgery. She says if the ACA subsidies expire, it will further delay the process.
The 51-year-old voted for Republican Donald Trump for president last year, which she said was almost embarrassing for her after the Republican-led administration failed to renew subsidies that would aid her secure her insurance coverage on the government market.
“I work hard and try to survive, do it right and pay my dues,” Meehan said. “I don’t want it to be free. I just want it to be affordable for my income.”
Even if Congress extends it, the delay could have consequences
Health policy analysts note that even if the subsidies are extended, insurance premium increases for 2026 will already be higher because insurers had to take their potential expiration into account when setting premium prices earlier this year.
There are also concerns that the delay will cause chaos, confusion and stress among Americans, some of whom have already received notices that their premiums will skyrocket next year.
“Once those people say, ‘Oh, wait, forget it, I’m out,’ it’s going to be difficult to get a lot of them back,” said the Urban Institute’s Levitis.
Monreal’s husband will likely need to have both knees replaced, which will force him to take time off from his job as a concrete worker. Given their already tight combined annual income of $45,000, budgeting for themselves and their five children becomes even more challenging.
Concern about her budget and uncertainty about her health insurance are sending her into another worrying spiral, with only two weeks until open enrollment.
“They didn’t tell us anything,” she said of her insurer. “And you know what? You end up with no health care.”
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Swenson reported from New York. Associated Press video journalist Tassanee Vejpongsa contributed to this report.
