As the federal government shutdown approaches a month in length, the fight over access to health care for Americans is at the center of the standoff between Republicans and Democrats.
Democrats want to extend enhanced tax credits for people who use the Affordable Care Act marketplace that are set to expire at the end of the year. Experts say this will cause insurance costs across the country to skyrocket, forcing some to become uninsured.
An estimated 24 million Americans now rely on the ACA, or Obamacare, to get their health insurance.
Democrats are also pushing to reverse cuts to Medicaid enacted as part of President Donald Trump’s sweeping tax and policy bill passed this summer.
U.S. Rep. Raja Krishnamoorthi recently toured Loretto Hospital in Chicago’s Austin neighborhood to hear about how changes to Medicaid could hit the hospital. He said the loss of the enhanced ACA subsidies could also ripple out to safety net hospitals and cause a “huge catastrophe.” The shutdown began Oct. 1 after Congress missed the deadline to fund the government.
“Once they lose their health insurance, they’re going to go to the emergency rooms at places like Loretto, and then everyone’s health insurance premiums are going to spike,” he said
Here’s what you need to know about the ACA tax credits at the heart of the federal shutdown.
What tax credits are at stake?
With passage of the Affordable Care Act, tax credits were used to reduce monthly premiums for low-income Americans, said Stephanie Altman, director of the health care justice team at the Shriver Center on Poverty Law. The credit size is based on income — the lower your income, the larger your credit.
Then in 2021 during the COVID-19 pandemic, an enhancement to the premium tax credit was added. It makes ACA plans even more affordable by creating deeper levels of financial assistance and offering reduced benefits to middle-class enrollees that phase out as income rises. The credit caps premium contributions as a percentage of income.
“The problem was a lot of people were losing their jobs or not working,” said Robert Kaestner, a health economist at the University of Chicago’s Harris School of Public Policy. “They didn’t have access to employer-provided insurance, which they usually would, so the expanded tax credits were just a way to kind of support people in this very unusual time.”
But the enhanced credit is expiring, leaving only the premium credit. The enhanced credit allows someone with income above 400% of the federal poverty level to use the premium tax credits at a reduced level, according to KFF, a health policy organization. That’s $128,600 for a family of four. This group will no longer receive the reduced subsidy unless the enhanced credit is extended. And critically, everyone who is still eligible for the regular credit is expected to pay more.
How many people in Illinois will be affected?
Across Illinois 465,985 people in 2025 bought their health insurance through the ACA, according to a letter penned by the Democratic Illinois congressional delegation.
More than 395,000 of those people benefit from the enhanced premium tax credits, according to KFF.
Though it’s hard to say exactly how many people will no longer be able to afford health insurance without the enhanced tax credit, state officials predict an estimated 70,000 to 90,000 people in Illinois will become uninsured, Altman said.
This comes as people getting insured through the ACA has increased in recent years. In 2020, there were just 292,945 enrollees, according to the Illinois congressional delegation. Illinois saw a record 17% increase in enrollees last year, state officials say.
How much will premiums increase?
The estimated premium increase without the enhanced tax credit varies across the state. For example, it could range from $696 to $1,776 annually in Illinois, according to an analysis from the Center on Budget and Policy Priorities, a D.C.-based think tank.
Enrollees are expected to have to contribute a larger share of their income toward an ACA plan, according to KFF. For example, a person making $28,000 a year will go from paying 1% to 6% of their income for an ACA plan.
“It will not be as generous and for many people insurance will become unaffordable for them,” Altman said.
But Kaestner said both Republicans and Democrats have exaggerated claims about the effects of the end of the enhanced tax credits, noting that the cost of living and affordability varies across the country.
He thinks the number of people who will become uninsured will be closer to 2 million people nationally — less than the 4 million the Congressional Budget Office is predicting — because others will be able to get insurance through their employer or through other means.
On top of the changes to tax credits, health care costs are also expected to rise because of the impact of tariffs on pharmaceuticals and general inflation.
“It’s a triple whammy that’s hitting consumers in addition to the normal rise in health care costs,” said Ann Gillespie, director of the Illinois Department of Insurance.
What’s ‘Get Covered Illinois’?
For the first time, residents in Illinois this year can sign up for the ACA in the new state-run marketplace called “Get Covered Illinois.” It launches Nov. 1, when open enrollment begins.
Enrollment should not be impacted by a continued federal government shutdown because the marketplace is state-operated, Gillespie said.
Illinois is investing in ACA navigators to help individuals find a health care plan, Gillespie said. The new marketplace will also have a 350-person call center with translation services.
Gillespie is encouraging ACA enrollees who receive notices of rising premiums to take advantage of the new state services. While the state can’t make up for the loss of the enhanced premium tax credits, navigators and call centers workers can help people apply for Medicaid or try to find a more cost-effective plan “that will suit their budget and their health care needs.”
“So we really encourage people not to give up,” Gillespie said.
Open enrollment runs from Nov. 1 to Jan. 15. You can call the center at 1-866-311-1119 or visit getcovered.illinois.gov.