Not long ago, we cared for a young man admitted to the intensive care unit nearly comatose, his blood sugar so high it threatened his life. He was suffering from diabetic ketoacidosis. It was his second ICU admission in a month.
He had recently lost access to the insulin that had kept his diabetes under control. For weeks he rationed what he had left, hoping he could hold out until he found a solution. His body gave out first.
As physicians who treat critically ill patients, we are seeing stories like this more often.
Early-enrollment data already shows 1.3 million fewer people signed up for marketplace plans compared with last year, and analyses suggest that almost 5 million Americans could lose coverage entirely.
Sweeping health care cuts under the current administration have had severe, real-world implications, most glaringly the Jan. 1 expiration of the Affordable Care Act enhanced subsidies. Originally expanded during the Covid-19 pandemic, these measures sharply reduced monthly payments and drove record-setting enrollment in ACA plans. Rather than bolstering the ACA foundation by cementing these subsidies into law, Senate Republicans have deliberately allowed these protections to expire to reduce federal spending. This decision exposes a fragile system built upon temporary fixes that allows billions of taxpayer dollars into private insurance markets to keep coverage manageable.
Recent reporting has warned that the expiration of enhanced ACA subsidies could sharply raise premiums for millions of Americans and push many out of the insurance marketplace.
For policymakers in Washington, these changes may appear as budget lines or partisan disputes. For us, they are already visible in the ICU.
The pandemic-era subsidies capped premiums and helped millions of working Americans afford coverage, many for the first time. The abrupt expiration has suddenly removed that financial safety net. Some marketplace premiums could more than double without the subsidies, according to estimates from KFF. Early-enrollment data already shows 1.3 million fewer people enrolled in marketplace plans compared with last year, and analyses suggest that almost 5 million Americans could lose coverage entirely.
Many patients are trying to cope by switching to cheaper plans with lower premiums but far higher deductibles. Others are leaving the marketplace altogether. The result is a growing number of Americans falling off a subsidy cliff — people who technically have insurance but cannot realistically afford to use it.
In the ICU we hear the consequences often: skipped clinic visits, rationed medications and untreated chronic illness. When patients lose access to routine and preventive care, manageable diseases quietly progress until they erupt into medical emergencies. Research consistently shows that uninsured patients experience worse health outcomes because they receive less preventive and ongoing care.
We can stabilize patients once they arrive in crisis. But often we are applying an extraordinarily expensive bandage to a system that failed them long before they reached the hospital.
Many health policy proposals now circulating in Washington would move the system even further in the wrong direction. Some policymakers have promoted expanding high-deductible health plans by pairing them with health savings accounts, increasing access to bare-bones “catastrophic” coverage, or shifting more prescription medications to over-the-counter status. On paper, these proposals promise lower premiums and greater consumer choice. In practice, they largely shift costs onto patients.
One recent proposal from the current administration would raise the deductible for some plans to more than $15,000 for an individual. By common definitions of underinsurance used by the Commonwealth Fund, a plan with a deductible that high would require a household income well above $300,000 to remain truly affordable.
In the ICU we hear the consequences often: skipped clinic visits, rationed medications and untreated chronic illness.
Coverage design matters enormously. Nearly one-quarter of insured Americans already struggle to afford care. Patients enrolled in high-deductible plans are more likely to delay necessary treatment and more likely to require emergency department visits and hospitalizations. For patients with chronic illnesses like diabetes, these plans can be especially punishing because meaningful coverage often does not begin until the deductible is met.
The risk is an expanding epidemic of underinsurance — reinforcing an uncomfortable truth about the American health system. Much of it is not designed to keep people healthy. Instead, it often functions as financial protection against catastrophic illness once disease has already progressed.
If the United States wants a durable solution, policymakers must move beyond incremental adjustments and finally toward a single-payer national health insurance program: Medicare for All.
Public support for such a system is stronger than many policymakers acknowledge. Recent polling suggests roughly 65% of likely voters support a national health insurance program.
A single-payer system would address two structural problems in American health care. First, it would eliminate the extreme fragmentation created by thousands of private and employer-sponsored insurance plans — fragmentation that weakens patients’ bargaining power while strengthening the leverage of insurers and pharmaceutical companies. Second, it could dramatically reduce administrative waste. The United States devotes enormous resources to billing complexity, prior authorizations and insurance bureaucracy. A unified national insurer could negotiate prices directly while simplifying administrative infrastructure and shifting incentives toward long-term health through primary care and prevention. Critics often warn that single-payer systems lead to “rationed care.” But Americans already experience one of the harshest forms of medical rationing in the developed world: rationing based on the ability to pay. When a patient with diabetes ends up in the ICU because they cannot afford insulin or insurance premiums, care has already been rationed. We simply choose to pay for treatment only after the patient becomes critically ill. That choice is both cruel and economically irrational. A three-day hospitalization for diabetic ketoacidosis can generate up to $30,000 in charges, according to estimates from the Health Care Cost Institute, while a monthly insulin supply costs a fraction of that amount. Opponents often warn about the cost of transitioning to a single-payer system. Yet the status quo is itself economically unsustainable. The United States already spends almost 18% of its gross domestic product on health care — far more than other wealthy countries — and that share continues to grow, according to the Centers for Medicare and Medicaid Services. Our patient eventually recovered. When he left the hospital, we were able to send him home with a month’s supply of medications that would control his blood sugar. What we could not provide was the stability that would keep him healthy after that. His case is a reminder that when patients cannot afford insurance or basic medications, routine care disappears until disease becomes catastrophic. We can keep saving them in the ICU But until lawmakers build a system that prevents these crises in the first place, we will keep seeing them there.
Hasan Nadeem, M.D., is a pulmonary and critical care fellow physician who writes about health policy from the front lines of the Intensive Care Unit.
Vin Gupta, M.D., is a pulmonary and critical care physician, public health expert, and a medical analyst for MS NOW. 
