A government shutdown that lasted more than 43 days has ended, but for millions of Americans, the uncertainty has only begun. In striking a deal to reopen federal agencies, lawmakers failed to extend the Affordable Care Act’s enhanced subsidies, the financial assistance that keeps health insurance affordable for 24 million people nationwide. The Senate’s Republican majority leader promises a vote in December. For families facing coverage renewal deadlines, that is too late.
I have seen what happens when people can’t afford to see a doctor until it is too late.
As a physician who has spent more than a decade treating patients in emergency rooms, I have seen what happens when people can’t afford to see a doctor until it is too late. And as founder and CEO of Advancing Health Equity, I have watched organizations wrestle with how to make care accessible and sustainable. Not having extended the subsidies already is more than a procedural failure; it is a failure of governance, compassion and foresight.
The ACA subsidies were first expanded during the Covid-19 pandemic to prevent millions of Americans from losing their coverage. They have since become the backbone of marketplace affordability. According to the health policy research firm KFF, if these subsidies expire, then the average annual premium payment for subsidized enrollees could more than double, from $888 this year to about $1,904 in 2026.
That increase would be devastating for middle-income families who already live close to the margin. It would also widen racial and regional inequities. Black and Latino enrollees, who are disproportionately represented among the newly insured, would be among the hardest hit.
The current standoff over ACA subsidies is far more than just another Washington budget fight. It is a struggle over whether affordability and access to care are considered essential or expendable. These subsidies are not corporate handouts; they are lifelines that flow directly to consumers in the form of lower premiums.
Reducing those subsidies to a bargaining chip not only jeopardizes families’ health care coverage, it also erodes trust in government itself. The idea that Congress can shut down the government over affordable health care, delay action on extending these subsidies and maybe not extend them at all shows how far we have drifted from the basic principle that health care should be stable and not subject to political cycles.
If Congress fails to act before year’s end, then we will see a perfect storm. Families who haven’t already will open renewal notices showing premiums hundreds of dollars higher each month. States will have to scramble to refile insurance rates and update marketplace systems. Insurers will raise prices preemptively, anticipating a sicker risk pool. Clinics and hospitals will absorb the fallout when newly uninsured patients show up in crisis.
For many Americans, the shutdown may be close to over, but the shutdown of their access to affordable coverage may be just beginning.
Because I have cared for the most marginalized patients in public hospitals as an emergency physician, health policy is not abstract to me. I have seen how systemic inequities show up in the most intimate ways, when someone comes in because they delayed care or because they had nowhere else to turn.
When we talk about health equity, we are talking about making sure that a mother in Mississippi or a gig worker in Queens does not lose coverage because Congress can’t keep the lights on. We are talking about keeping families from choosing between insulin and rent.
The expiration of these subsidies would undo much of the progress we have made since the pandemic in narrowing coverage gaps. It would also send a chilling message to every organization trying to build trust with marginalized communities: that even hard-won gains can vanish overnight. Health care affordability should never hinge on partisan brinkmanship. Congress must immediately pass an extension of the enhanced ACA subsidies before the marketplaces finalize 2026 rates. That is not just smart policy; it is basic governance. Lawmakers should extend the subsidies for at least two years to provide stability for families and insurers alike, pair the extension with transparency measures to ensure funds directly reduce consumer costs and create a long-term road map that ties federal support to measurable outcomes in coverage, quality and equity. Health care affordability should never hinge on partisan brinkmanship. These subsidies have broad, bipartisan public support, nearly 80% of Americans, according to a recent KFF poll. They are among the most cost-effective investments we can make in public health and economic resilience. As we approach another election year, the debate over ACA subsidies is about more than numbers on a balance sheet. It is a referendum on whether we still believe that access to care is foundational to a healthy democracy. Millions of families are watching Congress to see whether stability wins out over ideology. They deserve an answer now, not another round of shutdowns and delays. Because when Washington shuts down, patients do not stop getting sick. Bills do not stop coming due. And the health of a nation cannot be negotiated away.
Uché Blackstock, M.D., is the founder and CEO of Advancing Health Equity, best-selling author of "LEGACY: A Black Physician Reckons with Racism in Medicine" and a former MSNBC and NBC News medical contributor. 
