Because Congress failed to extend enhanced Affordable Care Act subsidies before they expired at the end of the year, millions of Americans woke up in 2026 to higher health insurance premiums. For many families, the increase will be sudden and unaffordable, and as a physician, I know what happens next: Some people will drop coverage entirely. Others will keep insurance in name only, avoiding care because of higher deductibles and higher out-of-pocket costs. Preventive visits will be postponed. Prescriptions will go unfilled. Chronic conditions including diabetes, hypertension and asthma will quietly worsen until they become emergencies.
Chronic conditions including diabetes, hypertension and asthma will quietly worsen until they become emergencies.
Then patients arrive in emergency rooms sicker and harder to treat.
Despite months of warnings from physicians, economists and patient advocates, Republicans declined to extend the subsidies, citing concerns about federal spending. Despite the dire consequences that loomed for so many of their constituents, members of Congress left for the holiday recess without coming to a last-minute deal or even a temporary fix. Dec. 31 wasn’t an abstract policy deadline but a health care cliff.
The Affordable Care Act itself remains in place. What has ended are the enhanced subsidies that made marketplace coverage affordable for millions of working families. Expanded during the pandemic, those subsidies helped drive the nation’s uninsured rate to a historic low of 8%. They allowed people who had always lived one illness away from financial disaster to stay insured.
The scale of the impact is significant. Federal estimates suggest that those who currently receive enhanced ACA premium subsidies could see their premium payments rise sharply, and in many cases more than double. For adults who are not yet eligible for Medicare, monthly costs could rise by hundreds of dollars.
For many families, those increases are not absorbable. They are destabilizing.
The effects will appear quickly across the health care system. Emergency departments will see more patients arriving later and sicker. Safety-net hospitals will absorb more uncompensated care. Community clinics will be overwhelmed by people trying to navigate sudden coverage loss. The pressure from these issues eventually affects staffing, services and access for everyone.
If these consequences weren’t dire enough, it’s also the case that the burden will not be evenly shared.
The consequences will cross political lines.
Adults age 50 to 64, who face higher premiums but are not yet eligible for Medicare, are among those most at risk. People living in states that did not expand Medicaid will have fewer alternatives when marketplace coverage becomes unaffordable. Black and brown communities, already more likely to experience chronic disease and medical debt, will feel the impact sooner and more severely.
The consequences will also cross political lines. Republican voters in red states will be affected as well, particularly those who are self-employed, work for small businesses or live in rural areas where employer-sponsored insurance is limited.
Supporters of allowing the subsidies to expire often frame the issue as one of cost or fiscal restraint. From a clinical perspective, that framing misses the reality on the ground. When people lose access to affordable care, costs rise. The Congressional Budget Office has repeatedly found that stable insurance coverage reduces preventable hospitalizations and lowers long-term spending.
Doing nothing was not and is not a neutral choice. It shifts illness, financial strain and risk onto patients with the least margin to absorb them. For patients, the question isn’t just whether Congress will act this month but also how to manage what comes next. Anyone who relies on ACA marketplace coverage should review January premium notices carefully and seek enrollment assistance if costs have spiked. Some states and insurers may offer limited stopgap options, but these are not substitutes for affordable coverage. Patients should understand this clearly: If health insurance has become unaffordable, that is not a personal failure. It is a policy failure. The problem is that health care in the United States is overpriced to begin with. The problem isn’t just that subsidies are expiring. The problem is that health care in the United States is overpriced to begin with. We pay more for hospital care, prescription drugs and administrative complexity than any other wealthy nation, and those costs are baked into premiums. Subsidies are a critical lifeline in that system, but they do not lower prices. When we don’t confront the underlying drivers of health care costs, we are not fixing the problem. We are simply shifting it. The need for health care does not pause because Congress does. Patients do not get extensions on cancer, heart disease or asthma because lawmakers missed a deadline. The subsidies have expired. The harm has begun. Without swift action, this health care cliff will deepen inequities and cost lives.
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. 
