Of Lisa Jarvis

At the heart of the government shutdown is the fate of health insurance for millions of Americans, who may soon face a weak choice: to accept a significant increase in their premiums or take the risk and abandon their insurance coverage.

About 4.2 million people are expected to lose their insurance coverage if Congress does not extend premiums for the Affordable Care Act programs, according to the Congress Budget Office. A separate analysis by the KFF Research Foundation found that without the subsidies, which are going to end at the end of the year, the average annual premiums will be more than doubled – from $ 888 this year to $ 1,904 in 2026.

Democrats want the subsidies to be extended permanently, while the Republicans are ready to let them end. Democrats also want to reinstate Medicaid funding that was cut by the law “a big beautiful bill”.

It is a political battle that has real consequences for millions of Americans, many of whom hold (or work for) small businesses, or deprived and saved to retire prematurely. “These are their friends, neighbors and colleagues who will lose their safety and their health will suffer as a result,” says Rachel Werner, executive of the Leonard Davis Institute of Economics at the University of Pennsylvania.

In the complex US healthcare system, public opinion has long been difficult to understand how policy changes can affect it. And the issue of ACA subsidies (Affordable Care Act) is particularly complicated. One issue is that the expiry of additional tax credit, which is entitled to more than 90% of current registered, will not affect everyone equally. Some will see sharp increases in interest rates as they will completely lose subsidies. Others will continue to receive some help, though smaller. (And to be clear, even a moderate increase in costs can have a significant impact on many households.) In the meantime, insurance companies respond to uncertainty by applying their own price increases, adding to the total cost of consumers.

The impact of this seemingly technical policy change will be huge. After the Biden government improved tax credits to make insurance more accessible to a wider population, the number of people buying programs through the market has more than doubled. At the same time, the number of uninsured Americans decreased to a historic low.

Who are the most at risk of losing their insurance coverage? Self -employed Americans, small business owners or those who work for small businesses with less than 25 employees. They represent 48% of adults who are insured in an ACA program, according to a new KFF analysis. This could disproportionately affect people living in rural areas, where small businesses represent a large proportion of jobs.

The other important group that will be affected is the people who retire prematurely. The ages of 50 to 64 years were once in an expensive impasse in health care between the previously funded by the employer coverage and the eligibility for Medicare. But increased subsidies have made market programs much more affordable, limiting their contribution to 8.5% of their income. Today, this team represents a little more than half of the ACA registered with incomes overflowing on the poverty line.

Without the extra credits, these people will not receive any help in paying their security. After years of careful planning, the cost of health care will be launched. A 60 -year -old couple living with $ 85,000 (just above the limit that would allow them to receive a subsidy) could see their monthly premium increase from about $ 600 to over $ 2,100 – or almost one -third of their household income, according to KFF.

And healthcare providers will feel pressure. Last week, the Robert Wood Johnson and the Urban Institute estimated that the expiry of reinforced tax credit would result in a loss of $ 32.1 billion for hospitals, doctors and other healthcare providers.

The most significant reduction in healthcare costs will be noted in the south, where a group of states has not yet adopted the extension of Medicaid, which allows anyone with family income below 138% of the federal poverty threshold to be entitled to public insurance. Subsidies have allowed people who live just above the poverty line in these 10 states who have not adopted the expansion to obtain a “silver program” at no cost. This significantly reduced the number of uninsured people in these states, where more than 6.2 million people in this income range were enrolled in market programs in 2025.

End of subsidies will hurt people hard living in these Republican states – and will lead to the highest reductions in health care costs, according to the analysis of the Robert Wood Johnson Foundation and the Urban Institute. Expenditure will be reduced by almost 5% in Florida, Georgia and Texas.

In the meantime, people who maintain their insurance coverage in November may find that they have fewer options available. Some insurance companies choose to withdraw from the market next year, arguing that the lack of additional subsidies will force healthier people to completely abandon the coverage, which would leave them with a more sick – and more accurate – group of patients.

Of course, subsidies are not free. The CBO (Congress Budget Office) estimates that maintenance of credit will cost about $ 350 billion in the next decade. And because enhanced subsidies are relatively new, it is too early to quantify their benefits – for example how access to preventive care could mitigate the weight of chronic diseases or reduce long -term healthcare costs.

Health policy experts point out reliable data on the impact on health, financial and economic impact of other important efforts to improve insurance coverage – such as the extension of Medicaid – as a encouraging sign. And in June, Werner and her colleagues offered a more convincing reason for expanding subsidies: their termination would not only lead to a loss of insurance of about 5 million people, but would also result in 8,811 additional deaths.

This is an important reminder of the high stake that the abolition of a policy that has worked so well for so many Americans.

*Lisa Jarvis is a columnist for the Bloomberg Opinion covering biotechnology, health care and pharmaceutical industry. Previously, he was an executive author of Chemical & Engineering News.