The “Big Beautiful Bill” has negatively impacted Medicaid and SNAP benefits, harmed national and state economies, and increased pressure on state budgets across the country.
I discuss here the additional pain and hardship that would affect people who can only afford health insurance thanks to Enhanced Health Insurance Tax Subsidies (EHITS), subsidies designed to help those who would otherwise spend over 8.5% of their income on healthcare premiums. For more than forty days, Senate Democrats had steadfastly fought to keep these subsidies in place. However, Republicans had refused to negotiate on this matter. On November 11, eight Democrats joined Republicans to vote for extending federal government funding through January’s end, largely in exchange for a promised US Senate vote in December on the issue of extending EHITS.
There are compelling reasons to extend the Affordable Care Act (ACA) EHITS. Since 2014, the ACA has placed caps on enrollee premium payments based on income. In response to the COVID-19 pandemic in 2021, enhanced ACA subsidies were introduced, resulting in a substantial increase in enrollment—from 11 million to 23.4 million as of February 2025. These enhanced subsidies have significantly improved the affordability of health insurance for many Americans. If the federal government allows these subsidies to expire at the end of 2025, the average enrollee’s health insurance premiums (HIPs) are expected to more than double, even before accounting for the projected 26% average increases in ACA health insurance policies. The Congressional Budget Office (CBO) estimates that about 1.5 million Americans will lose their health insurance in 2026 alone and 3.8 million by 2035 because of unaffordability. Pennsylvania’s health insurance marketplace, PENNIE, projects that 245,000 residents will lose their health coverage due to increased unaffordable HIPs in 2026.
KFF (Kaiser Family Foundation) estimates that a single 45-year-old who earns $45,000 per year will pay an additional $2,419, $1,207 in lost subsidies and $1,212 in higher premiums. A 60-year-old couple earning $85,000 a year will pay an additional $18,080 due to the loss of the subsidy and an increase in HIPs of $4,555, totaling $22,635, over 25% of that couple’s income.
Many Americans’ budgets are already stretched severely by their food, housing, utilities, and transportation costs. Drew Altman of KFF points out in a recent article that “Red states,” which did not expand Medicaid will be hit particularly hard by the expiration of the EHITS.
One fourth of all ACA enrollees are either small business owners or self-employed. One fourth of all farmers purchase their health insurance through the ACA. According to an October 14, 2025 Pennsylvania Insurance Department press release, “a 60-year-old married couple in York County with $82,000 in annual income will see their yearly premium skyrocket from $7,032 to $35,712 per year.
A recent article published by The Commonwealth Fund concludes that the loss of EHITS will drop rural hospitals’ revenues by $1.6 billion across the US and will reduce their margins by 10% in 2026, hospitals that are already barely holding on financially.
On the cost side of extending EHITS, the CBO projects the federal deficit will rise by $350 billion from 2026 to 2035 if ACA premium subsidies are extended.
Some might say our nation simply cannot bear another increase to the federal deficit because these expanded health insurance subsidies are too costly. I totally agree that using taxpayer money to feed the excessive greed of the middlemen of medicine, including the health insurance industry, the pharmaceutical industry, pharmacy benefit managers, and even healthcare executives’ exorbitant salarie,s is something that we should curtail. This is why I have advocated for ‘Improved Medicare for All” since 2007. However, if these enhanced ACA subsidies are not extended, there will be much avoidable pain and suffering exacted on the less fortunate among us. There will be unnecessary deaths!
As of today, there is a promised upcoming December vote in the US Senate on this very issue. Please contact your senators (John Fetterman: 202-224-4254) and David McCormick (202-224-6324) to let them know how you feel about this issue, and that they should vote for the extension of EHITS. Better yet, let them know that it is far beyond time to work on meaningful change to reduce the costs involved in our healthcare system, a system in which we spend more than twice as much on healthcare as nearly any other industrialized nation on earth. Establishing a bipartisan committee dedicated to addressing the issue of excessive profit within the healthcare sector could improve affordability for everyone, both now and in the future.
Dwight Michael, M.D., a retired primary care physician, is a member of the Gettysburg DFA Health Care Task Force. He lives in Gettysburg.