TYLER, Texas (AP) — Celia Monreal worries every day about cartilage loss in her husband’s knees. Not only because it hurts her to see him suffer, but also because she can easily understand how they feel. Medical costs may rise rapidly.
Monreal (47 years old) and her husband Jorge (57 years old) Affordable Care Act Marketplace For health insurance. If Congress does not extend certain deadlines ACA tax credit Fully subsidized plans, which are set to expire at the end of the year, will increase costs and make them unaffordable. Without insurance, she wouldn’t be able to pay for her planned knee replacement surgery, much less get the treatment she needs for other problems, such as her chronic high blood pressure and high cholesterol levels.
Celia Monreal holds some of her and her husband’s medication as they pose for a photo at their home in Tyler, Texas, on Wednesday, Oct. 8, 2025. (AP Photo/Tony Gutierrez)
“Sometimes I worry because if I’m not healthy, I won’t be here for my kids,” Monreal said. “It’s a tough decision, because should I spend $500 on a doctor’s visit or should I buy groceries?”
These types of choices are faced millions of Americans That state or federal marketplace health insurance plan renews in November. The enhanced premium tax credit that has made insurance more affordable for low- and moderate-income enrollees for the past four years is set to expire this year. unless Congress extends it. On average, subsidized members will pay more than double the premiums they currently pay next year, according to the report. analysis By KFF, a healthcare research nonprofit.
Mainly tax deductions federal government shutdownin the third week I can’t see the end. Democrats are demanding an extension of the aid as part of any funding deal they sign, but Republicans say they will only negotiate the issue once the government is funded.
and Congress is deadlocked And with the open enrollment period for ACA plans approaching Nov. 1 in most states, Americans like Monreal are left navigating an unknown.
A page from the Affordable Care Act health insurance website healthcare.gov appears on a computer screen in New York, August 19, 2025. (AP Photo/Patrick Sison, File)
Without an extension, insurance premiums will go up for millions of people.
more 24 million people People with ACA health insurance are a group that includes farmers, ranchers, small business owners, and other self-employed people who do not have other health insurance coverage because of their work.
The enhanced premium tax credit, which is set to expire this year, will make costs much more manageable for many enrollees, allowing some low-income enrollees to receive premium-free care and allowing higher-income enrollees to pay less than 8.5 percent of their income.
If the tax credit were to expire, out-of-pocket insurance premiums would increase next year by 114% (an average of $1,016) next year, according to KFF’s analysis.
Some premium tax credits will remain, but the level of support for most enrollees will be reduced. People who earn more than 400% of the poverty level, or about $63,000 a year if they are single. no qualifications As for the remaining tax credits.
As a result, the hardest-hit groups include a small number of high-income people who would have to pay more without additional subsidies, and a large number of lower-income people who would have to pay a little more, said Cynthia Cox, vice president and ACA program director at KFF.
Cox said higher premiums could lead some people to opt out of health insurance altogether. When many young, healthy people inevitably forego insurance, insurance companies will increase costs for policyholders because they are older and sicker.
The change could also put a strain on hospitals as more uninsured people require emergency care they can’t afford. This could lead to hospital closures and increased costs.
“If you have less subsidies for people to buy health insurance, you’re going to have less health insurance, you’re going to have less health care,” said Jason Levitis, a senior fellow in the Urban Institute’s health policy division. “People are going to get sicker and die more.”
Caregivers are preparing for the worst. Filmmaker considering new job
Erin Jackson Hill suffers from allergies, asthma and burning pain in her hip, which she is managing with prescription medication until she can have a hip replacement. But even with all these conditions, the 56-year-old Anchorage, Alaska, resident doesn’t think she will be able to pay for her health insurance next year unless ACA subsidies are extended.
The executive director of two nonprofit organizations also cares for her 89-year-old father full-time and already pays nearly $500 a month in insurance premiums. Once the subsidy runs out, she plans to drop her health insurance and pay for her asthma and allergy medication out of pocket.
Jackson-Hill said she was worried about what would happen if her hip deteriorated and she was unable to climb the stairs in her father’s two-story home without treatment.
“You have to go to the emergency room or you have to go bankrupt to pay for it,” she said.
Another ACA enrollee, Stan Clawson, a freelance filmmaker and adjunct professor in Salt Lake City, said he expects to find a way to pay for health insurance next year, even if it means buying cheaper groceries or getting a new job that provides them.
Clawson, 49, has lived with paralysis below her abdomen since falling while rock climbing when she was 20 years old. Although he is active and generally healthy, a spinal cord injury has caused tendinitis in his shoulder and he suffers from frequent urinary tract infections.
He also has to buy a catheter, which he uses every time he urinates, which costs about $1,400 a month without insurance, he said.
“I think a lot of people don’t realize how expensive it is to have a disability,” Clawson said, adding that trying to live without health insurance is “financially devastating.”
Local hairstylist Kristin Meehan sits in front of her medication as she talks about potential increases in health insurance premiums at her home in Upper Chichester, Pennsylvania, Monday, Oct. 13, 2025. (AP Photo/Tassanee Vejpongsa)
Chrissy Meehan, a hairstylist from Upper Chichester, Pennsylvania, has a neck condition that may require surgery. She says the process will be further delayed once ACA subsidies expire.
The 51-year-old voted for Republican Donald Trump for president last year and said she is now almost embarrassed that the Republican-led government has not renewed subsidies to cover her premiums through the state marketplace.
“I’m working hard, trying to survive, working the right way, trying to pay my bills,” Meehan said. “I don’t need free. I just want something affordable for my income.”
Delays could have an impact even if Congress is extended
Health policy analysts say that even if subsidies are extended, it will be difficult to raise premiums in 2026. already high That’s because insurers had to take the possibility of lapses into account when pricing premiums earlier this year.
There are also concerns that the postponement will cause confusion, confusion and stress for Americans, some of whom have already begun receiving notifications that their premiums will increase next year.
“If these people say, ‘Oh, wait, forget it, I’m leaving,’ it’s going to be hard to get a lot of people back,” said Levitis of the Urban Institute.
Celia Monreal and her husband Jorge, left, pose for a photo on the front porch of their home on Wednesday, Oct. 8, 2025, in Tyler, Texas. (AP Photo/Tony Gutierrez)
Monreal’s husband will likely need both knees replaced, which would mean he will have to take time off from his job filling concrete. With an already tight joint annual income of $45,000, budgeting for themselves and their five children will become even more difficult.
Budget concerns and uncertainty about health insurance coverage send her thoughts into an even more alarming spiral with just two weeks to go until the open market.
“They didn’t tell us anything,” she said of the insurance company. “And, you know, you end up not having access to health care.”
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Swenson reported from New York. Associated Press video journalist Tasany Vejiponsa contributed to this report.