TYLER, Texas (AP) – Celia Monreal worries every day about the loss of cartilage in her husband’s knees. Not only because it’s hard for her to see him in pain, but also because she knows that their health care costs may soon increase.
Monreal, 47, and her husband, Jorge, 57, rely on the Affordable Care Act marketplace for their health insurance. If Congress doesn’t extend certain ACA tax credits that expire at the end of the year, the cost of their fully subsidized plan will increase, making it unaffordable. Without insurance, they won’t be able to afford knee replacement surgeries for him, much less the treatment they need for other issues like her chronic high blood pressure and high cholesterol.
“It worries me sometimes because if you’re not healthy, then you’re not here for your kids,” Monreal said. “It’s a tough decision because, well, do I spend $500 on a doctor’s visit or do I buy groceries?”
Millions of Americans whose state or federal marketplace health insurance plans will renew in November have those choices. Enhanced premium tax credits, which have made coverage more affordable for low- and moderate-income people over the past four years, will expire this year unless Congress extends them. On average, that will double what currently subsidized students pay in tuition next year, according to an analysis by the health care research nonprofit KFF.
Tax credits are the main week of the federal government shutdown, with no end in sight. Democrats have demanded that the subsidies be extended in any funding deal they sign, while Republicans say they will negotiate on the issue only if the government is funded.
With Congress deadlocked and the open enrollment period for ACA plans approaching Nov. 1. in most states, Americans like Montreal are left to navigate the unknown.
No extension will mean higher premiums for millions
More than 24 million people have ACA health insurance, a group that includes farmers, ranchers, small business owners and other self-employed people who have no other health insurance options through their jobs.
Increased premium tax credits, which expire this year, have made costs much more manageable for many, allowing some lower-income earners to get health care without premiums, while higher earners can pay up to 8.5% of their income.
After the tax credits expire, annual out-of-pocket payments are expected to increase by 114% next year to an average of $1,016, according to KFF’s analysis.
While some premium tax credits will remain, the level of support will be reduced for many entrants. Anyone earning more than 400% of the poverty level (or about $63,000 per year for a single person) will not be eligible for the remaining tax credits.
That will leave the hardest-hit groups with a small number of higher earners who will have to pay a lot more without additional subsidies, and a lot of lower earners who will have to pay a little more, said Cynthia Cox, vice president and director of KFF’s ACA program.
With higher premiums, some people will drop out of health insurance altogether, Cox said. As many younger, healthier people inevitably drop insurance, insurance companies will increase the cost of the insured population to account for the fact that they are older and sicker.
The changes could also strain hospitals because more uninsured people will need emergency care they can’t afford. This could lead to hospital closures or increased costs.
“If you have fewer subsidies for people with health insurance, you’re going to have less health coverage and less health care,” said Jason Levitis, a senior fellow at the Urban Institute’s health policy division. “More people will get sick and die.”
The nurse is prepared for the worst. A filmmaker is considering a new job
Erin Jackson-Hill has allergies, asthma and burning hip pain, which she is managing with prescribed medication until she can have a hip replacement. But even with all those conditions, the 56-year-old woman in Anchorage, Alaska, doesn’t think she’ll be able to pay for 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 in her premiums. If the subsidies disappear, she plans to forgo health insurance and pay for her asthma and allergy medications out of pocket.
Jackson-Hill said she worries about what will happen if her hip worsens and she can’t climb the stairs in her father’s two-story home without treatment.
“I’m going to have to go to the emergency room or I’m going to have to go bankrupt to pay for it,” she said.
Another ACA student, Salt Lake City freelance filmmaker and adjunct professor Stan Clawson, said he will find a way to pay for health insurance next year — even if it means buying cheaper groceries or getting a new job that provides it.
Clawson, 49, has lived with paralysis below his abdomen since falling while rock climbing in his 20s. He is active and generally healthy, but with shoulder tendonitis and frequent urinary tract infections due to a spinal cord injury.
He also has to buy catheters to use every time he urinates, which he says would cost about $1,400 a month without insurance.
“I don’t think a lot of people realize how expensive it is to have a disability,” Clawson said, adding that trying to live without health insurance would be “financially devastating.”
Chrissy Meehan, a hair stylist in Upper Chichester, Pennsylvania, has a neck condition that may require surgery. She says if the ACA subsidies end, she will further delay the procedure.
The 51-year-old voted for Republican Donald Trump for president last year, which she says makes her almost ashamed now that the Republican-led government has not renewed subsidies that help her stock the state’s market.
“I work hard and try to survive and do it right and pay my price,” Meehan said. “I don’t want free. I just want my income to be accessible.”
Even if Congress continues, the delay could have consequences
Health policy analysts note that even if the subsidies were extended, in 2026 insurance premiums have already been increased because insurers had to take into account their potential expiry when setting premium prices earlier this year.
There are also worries that the delay will cause chaos, confusion and stress for Americans, some of whom have already begun receiving notices that their premiums will rise sharply next year.
“Once those people say, ‘Oh wait, forget it, I’m leaving,’ it’s going to be hard to get a lot of them back,” said the Urban Institute’s Levitis.
The Montreal man will likely need both knees replaced, which will force him to spend time filling with concrete. Their already low annual income of $45,000 will make budgeting for themselves and their five children much more difficult.
Concerns about their budget and uncertainty about health care coverage send her mind into yet another anxious spiral, just two weeks before open enrollment begins.
“They didn’t tell us anything,” she said of her insurance provider. “And you know what? You end up not having health care.”
___
Swenson reported from New York. Associated Press video reporter Tassanee Vejpongsa contributed to this report.