Health care subsidies are at the heart of the lockdown fight. Here who loses if it expires

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 their health care costs may soon rise.

Monreal, 47, and her husband, Jorge, 57, rely on the Affordable Care Act’s marketplace for health coverage. If Congress doesn’t extend some of the ACA’s tax breaks that are set to expire at the end of the year, their fully subsidized plan will increase the cost, putting it out of reach. Without insurance, they will not be able to afford the expected knee replacement surgeries, let alone the treatment they need for other problems, such as chronic high blood pressure and high cholesterol.

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“It worries me sometimes, because if you’re not healthy, 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?”

These are the kinds of choices facing millions of Americans whose health insurance plans on the state or federal marketplace will be up for renewal in November. Enhanced tax credits that made coverage more affordable for low- and moderate-income enrollees over the past four years will expire this year if Congress does not extend them. On average, that would result in more than double what currently subsidized enrollees pay for premiums next year, according to an analysis by the health care research nonprofit KFF.

Tax breaks are at the core of the federal government shutdown, in its third week with no end in sight. Democrats have called for an extension of support as part of any funding agreement they sign, while Republicans say they will not negotiate the issue until after the government is funded.

With Congress deadlocked and the Nov. 1 open enrollment period for ACA plans approaching in most states, Americans like Montreal are left to navigate the unknown.

Any extension would mean higher premiums for millions

More than 24 million people have health insurance from the ACA, a group that includes farmers, ranchers, small business owners and other self-employed people who have no other health insurance options through their work.

Enhanced tax credits set to expire this year have made costs more manageable for many of them, allowing some low-income enrollees to get health care without premiums, and for those with higher incomes to pay no more than 8.5% of their income.

If the tax credits end, out-of-pocket annual premiums are expected to increase 114% — an average of $1,016 — next year, according to a KFF analysis.

While some premium tax credits will remain, the level of support will decrease for most enrollees. Anyone earning more than 400% of the poverty level — or about $63,000 a year for a single person — will not be eligible for the remaining tax credits.

As a result, particularly hard-hit groups will include a small number of higher earners who will have to pay more without the additional subsidies and a large number of lower income earners who will have to pay a small amount more, said Cynthia Cox, vice president and ACA program director at KFF.

As premiums rise, some people will opt out of health insurance altogether, Cox said. When many younger, healthier people inevitably drop coverage, insurers will increase costs to members of the covered population to account for them being older and sicker.

This change could also strain hospitals, since more uninsured people will need emergency care they cannot afford. This could lead to hospital closures or increased costs.

“If you have less subsidies for people who get health insurance, you’ll have less health coverage and less health care,” said Jason Levitis, a senior fellow in the Department of Health Policy at the Urban Institute. “People will get sicker and die more.”

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Erin Jackson Hill suffers from allergies, asthma and severe hip pain, which she manages with prescription medications until she can get a hip replacement. But even with all those conditions, the 56-year-old who lives in Anchorage, Alaska, doesn’t think she can pay for health insurance next year if ACA benefits aren’t extended.

The executive director of two nonprofits, who also cares for her 89-year-old father full-time, pays nearly $500 a month for her insurance premiums. If the subsidies disappear, she plans to give up health insurance and pay for her asthma and allergy medications out of her own pocket.

Jackson Hill said she worries about what will happen if her hip worsens and she is unable to walk up 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 be able to pay for this,” she said.

Another ACA enrollee, independent filmmaker and assistant professor Stan Clawson, in Salt Lake City, said he will find a way to pay for health insurance next year — even if it means he has to buy cheaper groceries or get a new job that provides it.

Clawson, 49, has had paralysis of his lower abdomen since a fall while rock climbing when he was 20. He is active and generally healthy, but his spinal cord injury resulted in tendonitis in his shoulders and recurrent urinary tract infections.

He also has to buy a catheter to use every time he urinates, a cost he said would add up to 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.”

Chrissie Meehan, a hairstylist in Upper Chichester, Pennsylvania, has a neck condition that may require surgery. She says if the ACA’s subsidies expire, it will delay the action further.

The 51-year-old voted for Republican Donald Trump for president last year, something she said she feels almost embarrassed about now that the Republican-led government has not renewed the subsidies that help her afford her coverage through the state’s marketplace.

“I work hard, try to survive and do it the right way and pay myself,” Meehan said. “I don’t want free. I just want it to be affordable for my income.”

Even if Congress extends its term, delays could have consequences

Health policy analysts point out that even if the subsidy is extended, the 2026 insurance price hike is already higher because insurers had to take into account the possibility of it expiring when they set premium prices earlier this year.

There are also concerns that the delay will cause chaos, confusion and stress for Americans, some of whom have already begun receiving notices that their insurance premiums will rise significantly next year.

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“Once these people say, ‘Oh, wait, forget it, I’m out,’ it’s going to be hard to get a lot of them back,” said the Urban Institute’s Levitts.

Monreal’s husband will likely need to have his knees replaced, which will force him to take time off from his job pouring concrete. Given their already meager combined annual income of $45,000, budgeting for themselves and their five children will become much more difficult.

Worries about their budget and uncertainty about their health care coverage send her thoughts into another worrying spiral just two weeks before open enrollment begins.

“They didn’t tell us anything,” she said of her insurance company. “And you know what? In the end, you end up without health care.”

Swenson reported from New York. Associated Press video journalist Tasani Vigbongsa contributed to this report.