Just over 40 days into the longest government shutdown in American history, the cord broke. The boosted premium tax credits that provided insurance to 22 million Americans will end on December 31, 2025. Premiums are skyrocketing, protections are disappearing, and the safety net is disintegrating. Americans are already grappling with reduced SNAP benefits. Now they’re losing health coverage as well. Congress has signaled that the most vulnerable are not only dispensable but also forgettable.

We’re medical professionals who have devoted years to navigating federal red tape, scrutinizing health policy, and advocating for patients who slip through the cracks. Doctors for America embodies thousands of healthcare providers who assert that health care is a fundamental right, not a privilege. We are aware of the statistics: insurance coverage preserves lives, enhances outcomes, and genuinely lowers long-term health care expenses. The ACA’s enhanced subsidies served as a lifeline, not just for patients, but for those of us trying to deliver care in areas where the closest hospital is 50 miles away and nearly half our patients lack insurance. The implications of the expiration of ACA subsidies are complex, influencing patients, physicians, and the broader health care systems.

An estimated 4 million Americans will suddenly lose their marketplace coverage and become uninsured. The Kaiser Family Foundation reports that premiums for ACA marketplace plans are set to soar by 18 percent in 2026 following the subsidy expiration. Enrollees with incomes surpassing 400 percent of the poverty line will face even steeper increases in costs. A couple aged 60 earning $85,000 might see their annual premium escalate by 440 percent, from $602 monthly to $2,652 monthly. [Image of chart comparing ACA premiums with and without enhanced subsidies] A 45-year-old with an income of $20,000 could find their payments climbing from nothing to $420 per month. The Century Foundation notes that rural enrollees will witness their out-of-pocket expenses more than double (a 107 percent rise), exacerbating the geographic and economic divides that already position health care as a luxury in rural America.

Covered California indicates that premiums will surge by 76 percent for Latino enrollees, 71 percent for Asian Americans, and 67 percent for Black Americans. These are the same communities already ravaged by SNAP reductions, already juggling multiple jobs without benefits, and already one medical crisis away from financial ruin. The enhanced subsidies weren’t flawless, but they were a beginning; a down payment on remedying decades of systemic inequity.

The Urban Institute anticipates a staggering $32.1 billion revenue shortfall for health care providers in 2026 alone, alongside a $7.7 billion increase in uncompensated care. Hospitals in Texas and Florida, states that declined Medicaid expansion, will face severe resource depletions. Pharmacies and physician practices will need to scale back services or shut down entirely, jeopardizing care in communities already teetering on the brink.

Here’s what frustrates us: This was avoidable. The enhanced credits enabled households with incomes exceeding 400 percent of the federal poverty level to qualify for subsidies, granting middle-income families their first genuine opportunity for affordable coverage. Enrollment reached unprecedented levels. The uninsured rate fell to historic lows. [Image of graph showing U.S. uninsured rate trends] We constructed this system to serve as a safety net during difficult times, only for it to collapse within a few years.

When coverage fades, patients do not disappear; they simply return in worse health. Emergency departments will be inundated with preventable conditions. Community health centers will strain under the burden of uncompensated care. Physicians like us will uphold the same oath while being compelled to ration care based on zip codes and financial situations.

We’ve been involved in federal policy long enough to understand how the system operates. Yet we also work in trauma units, operating rooms, and clinics, where the ramifications of political cowardice manifest through vital signs and ventilators. This includes the patient who ceases attending follow-ups for a traumatic brain injury as their deductible triples, the parents in the office fighting back tears as they choose between feeding their family and maintaining their coverage, and the millions rationing insulin and forgoing cancer screenings because Republicans and Democrats deemed them acceptable losses. These are not hypothetical scenarios. They are our Tuesdays.

The transition from preventative care to reactive care will be unavoidable. Health care systems should prepare themselves for a surge in emergency department visits for untreated heart failures, late-diagnosed cancers, and infections that advanced due to an inability to afford antibiotics. Patients with chronic conditions such as diabetes, hypertension, and mental health issues will be the first and longest to suffer because routine labs and follow-ups will be exorbitant luxuries. Missed vaccinations, cancer screenings, and preventative visits will undermine public health. Uncertainties in coverage will lead to instabilities in health and an increase in human suffering.

The cord isn’t slipping any longer, Congress. You have already released it. The patients will bear the initial burden. Then, the