‘One Way or Another’: As Affordable Care Act Subsidies Hang in Shutdown Limbo, Health Care Leaders Warn of Impacts

In her day-to-day work as Greater Valley Health Center’s applications specialist, Lori Jones educates people on their insurance options.

“There are different resources here for people I didn’t realize until I came into this position,” Jones said.

But Jones and Greater Valley Health have dealt with several shifts in the insurance realm in the past few years.

Between 2023 and 2024, Medicaid unwinding knocked more than 100,000 Montanans off their insurance plans. Then, earlier this summer, Congress passed H.R. 1, or the “One Big Beautiful Bill Act.” It baked work requirements into Medicaid, to go into place federally at the end of 2026. Montana is pursuing an earlier implementation through a Section 1115 waiver. It’s estimated that work requirements could push 17.5% of Montanans on Medicaid expansion off insurance. As of May, the state had 76,000 people on Medicaid expansion.

Those changes alone mean Greater Valley Health, which aims to provide care to everyone, regardless of income, has been strained.

“All of those people who lose that coverage then fall into our bucket, where they’re uninsured or underserved, and we have a sliding fee scale,” said CEO Mary Sterhan. “We call it the nominal fee. It’s not intended to be a barrier to get care. You know, for instance, at the lowest level, it’s $20 to see a physician here. That clearly doesn’t cover the cost of it, so then we have to figure out how to make that difference. And the bigger that pool gets, the more challenging it gets.”

And now, Sterhan, Jones and the rest of their team are bracing for another stress test. Without congressional action, the Affordable Care Act (ACA) enhanced premium tax credits will expire at the year’s end. Those tax credits, when they were first approved, aimed to lower the cost of ACA insurance plans for people between 100% and 400% of the federal poverty level. In 2021 and 2022, eligibility was expanded for people whose income was above 400% of the federal poverty level. People who receive the subsidies are those who are lawfully present in the U.S., are not eligible for public coverage and do not have affordable coverage from their employers.

“I get each side of it,” Jones said. “There are people who are, you know, grateful these subsidies exist and are an option for them. And then you’ve got, ‘I couldn’t survive without it,’ sort of thing, and then the others that, even with the subsidy, don’t value insurance enough to pay for it.”

The subsidies have become the political football at the center of the government’s current shutdown, which stretched into its 10th day Friday. Democrats have so far refused to approve a continuing resolution without including the expanded subsidies’ extension.

The uncertain fate of the tax credits will determine whether premiums rise sharply in November, more than doubling on average for those in the ACA marketplace. Should Congress fail to extend the subsidies, the Congressional Budget Office estimates nearly 4 million people would lose their insurance over the next decade. By and large, those are people who might not make enough money to afford health insurance out-of-pocket but make too much to qualify for Medicaid or other forms of public assistance.

According to February figures from the Centers for Medicare and Medicaid Services, 74,687 people in Montana enrolled in ACA insurance plans between the 2024 plan year and March 15, 2025. Ninety percent of those people received the premium tax credit. Montanans’ average premium per month sat at $635.44. The average tax credit received for those eligible was $544.77, bringing down average premiums after receiving the credit to $145.39 per month.

Sterhan and Jones explained the loss of the subsidies would likely force people to opt out of insurance because the cost no longer fits in their budgets. The expiration would also raise premiums for unsubsidized consumers.

In the Flathead, Sterhan said, stories of those who could lose out are “a lot more poignant than people think.”

“I just think there’s just a lot more at play here,” Sterhan said. “And it’s the person next to you in the grocery line. Like, you might not think so, but it’s the person next to you in the grocery line. Like, it’s somebody that you know.”

The Affordable Care Act first passed in 2010. Championed by former President Barack Obama and sometimes referred to as “Obamacare,” the legislation aimed to make health care affordable and expand Medicaid to cover all adults below 138% of the federal poverty level.

“I was working at Whitefish, at the hospital there,” Sterhan said. “And I can tell you that we saw a great relief in people once they had insurance. Like, we had a decrease in difficult patients in the ER, because people came in — before they had insurance — they came in prepared to fight to get the care that they needed or to get their loved one the care.”

Fifteen years later, more than 49 million people federally have enrolled in insurance through the ACA marketplace at some point. That figure comes out to about one in seven Americans who’ve received health insurance because of the ACA.

But the law is not without its critics. It’s a costly program, and some argue it has been a driver of increasing health care costs affecting consumers. Conservative support for the legislation has been tough to garner.

When the tax credits’ expansion passed in 2021, they were part of the American Rescue Plan Act, which received no Republican votes. Then-vice president Kamala Harris cast a tie-breaking vote for the legislation in the U.S. Senate. After the initial passage in 2021, Democrats voted to extend the subsidies to 2025. That extension happened through the Inflation Reduction Act, which again, did not receive any GOP support in Congress.

A recent KFF poll found 78% of people support extending the tax credits again. The same poll also found a majority of people worry the extension would require significant federal spending.

With the subsidies’ expiration date looming, some members of the GOP have called for an extension. At the beginning of September, POLITICO reported that a group of 10 GOP House members put forth legislation to extend the subsidies through 2026. A few Republican senators — Sens. Dan Sullivan and Lisa Murkowski of Alaska and Sen. Tommy Tuberville of Alabama — have expressed interest in extending them, too. Most recently, Rep. Marjorie Taylor Greene, R-Georgia, broke with her party ranks, writing on X that she was “absolutely disgusted that health insurance premiums will DOUBLE if the tax credits expire this year.” Her post also critiqued her own party for not having a plan to curb that impact.

In Montana, the state’s Republican commissioner of securities and insurance, James Brown, signed onto a letter from his office’s national organization in August advocating for the subsidies’ extension.

“Failing to extend the enhanced credits beyond the end of this year will have a major impact on the stability and affordability of state health insurance markets,” the letter stated. “The affordability of coverage would change for millions of enrollees, with many paying hundreds more per month. For millions, coverage would no longer be affordable.”

A spokesperson from Brown’s office declined to comment further about the letter or the shutdown.  

Even with some defectors, the Republican Party’s prevailing view remains. The subsidies were meant to be temporary, are too costly and have issues with fraud and abuse.

“We don’t deny the fact that there are increases coming in health care costs and insurance premiums, but it’s not because of the loss of this subsidy,” said Steve Daines, Montana’s Republican senior senator, in an interview with CNBC’s Squawk Box Oct. 1. He pinned the blame of increasing health care costs on inflation.

Daines spokesperson Gabby Wiggins wrote, “Senator Daines believes Obamacare is a failure and extending the subsidies President (Joe) Biden and the Democrat Congress put in place will make this failed government-run health care program even worse. Not extending them will save taxpayers nearly half a trillion dollars.”

The Congressional Budget Office estimates the cost of extending the subsidies throughout the next decade will total $350 billion.

In the shutdown blame game, Daines, and fellow Montana Republicans Sen. Tim Sheehy and Reps. Ryan Zinke and Troy Downing have pointed the finger at Democrats.

“Chuck Schumer and the Democrats are putting partisan games over the best interests of the American people, holding critical resources for our military, veterans, and hardworking Montana families hostage to appease their radical, far-left base,” Sen. Sheehy said. “The Democrats’ decision to shut down the government over COVID-era Obamacare subsidies is exactly the kind of far-left madness Americans rejected last November, and it’s time Democrats join Republicans in voting to open the government. I was elected on a promise to restore common sense in our nation’s capital, and I’ll keep voting to stop the Schumer Shutdown. Once the government is back open, I look forward to continuing to work on restoring regular order in the appropriations process and lowering health care costs for hardworking Montanans.”

Minority Leader Chuck Schumer and the Democratic Party, on the other hand, have tied the blame for the shutdown to the Republican Party, arguing it’s Republicans’ responsibility to negotiate with them for their votes on a continuing resolution to keep the government open.

“Donald Trump, Senator Daines, Senator Sheehy, Congressman Zinke, and Congressman Downing refused to negotiate and ensure that healthcare expenses don’t double for Montana families, who are already struggling under Donald Trump’s economy,” said Justin Ailport, the Montana Democrats’ interim executive director, in a statement about the shutdown. “While Republicans refuse to even show up to work, Democrats stand united: cancel the cuts, lower costs, and save health care for Americans.”

If the premium tax credits fail to be renewed and people are notified of rate increases in a few weeks, Jones, with Greater Valley Health, worries people won’t value a more-costly insurance plan enough to pay for it.

But health care’s cost for taxpayers remains, according to Bob Lopp, the CEO of Western Montana Mental Health Center.

“We as a society end up paying for it, one way or another,” Lopp said.

Lopp, Sterhan and Jones agree people opting out of health insurance means they’re less likely to receive routine check-ups and preventative care, and more likely only to visit a health care provider when issues have reached a crisis level.

Sterhan and Lopp point out having health crises, not to mention paying for the costs out of pocket, can be catastrophic for people who are already struggling.

“I mean, it’s just, you know, if you end up really sick and you end up in the ER and then you end up in the hospital and you’re gone for a few days, you can lose your job,” Sterhan said. “You can then lose your housing. I mean, it can have this ripple effect that are all the other problems we’re dealing with, right?”

If those people can’t pay for their care, the public absorbs those costs.

We as a society end up paying for it, one way or another.

Bob Lopp, CEO of Western Montana Mental Health Center

Lopp said in the mental health world, that happens because people in severe mental distress may require public resources. A sheriff deputy might pick them up, or the county’s crisis response team may be involved. If they must sit in a jail cell, rules may require them to be in their own cell. In turn, that space can’t house “bad guys,” Lopp said. Or, if they go to a hospital and can’t pay for their own treatment, somebody must pay those costs.  

A KFF analysis found that between 2015 and 2017, uncompensated care costs for the country’s uninsured population totaled $42.4 billion. At least $33.6 billion of those costs were covered by public funds, either from the federal government or through states and localities. The costs for uncompensated care were billions of dollars higher before and as the ACA came to fruition. Between 2011-2013, they totaled $62.8 billion.

“We’re way better off from a cost perspective to have most people insured, if not all people insured,” Lopp said.

Part of Greater Valley Health Center’s mission lies with making sure people can access care, even if they may struggle to afford it.

According to Jones, a lot of that effort comes with showing people their choices. While premiums might go up if the ACA subsidies expire, she said there are other ways to afford care. It’s a matter of knowing what options exist.

As the shutdown moves forward and consumers are notified of their premium rates at the beginning of November, Jones encouraged those with questions to reach out to Greater Valley Health Center, or to visit healthcare.gov for more information.

Brown, the state’s commissioner of securities and insurance, has also encouraged consumers to shop around as they prepare for potential premium increases.

“The rising cost of health insurance is one of the most urgent issues facing Montana families and small businesses,” read a press release from Brown’s office about the ACA.

In that release, Brown encouraged Montanans to reach out to the commissioner’s office for help navigating choices as well. More information is available here.

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