After 43 days, the longest federal government shutdown in U.S. history has ended. A spending bill was passed with bipartisan support from Democrats and Republicans. However, the future of the Affordable Care Act (ACA) remains uncertain, particularly regarding the ACA subsidies that help cover insurance premiums.

The subsidies, also known as tax credits, were a major point of contention during the shutdown. Originally part of the ACA legislation passed during the Obama administration, these tax credits were enhanced in 2021 under the Biden administration. The enhancements expanded eligibility and lowered income contribution caps. These enhanced premium tax credits are set to expire at the end of this year.

A Senate vote on extending the tax credits is scheduled for December. Health policy experts anticipate that if the credits are not extended, healthcare costs will rise next year, impacting both individuals and the broader healthcare system. Speaker of the House Mike Johnson, R-La., has not committed to a vote on extending the subsidies, stating that reforms are necessary. "Am I going to guarantee a vote on ACA unreformed COVID-era subsidies that is just a boondoggle to insurance companies and robs the taxpayer? We got a lot of work to do on that," Johnson said.

The extension of the tax credits was not included in a significant spending bill signed into law in July. Senate Majority Leader John Thune, R-S.D., confirmed that a vote on the tax credits will occur in December. Republicans argue that the pandemic-era expansions of the tax credits were excessive and seek to revert to the original credits. In contrast, Democrats warn that without the enhanced credits, millions could face high premiums or lose their insurance altogether.

Justin Markowski, an assistant professor at the University of Illinois Chicago, noted that the tax credits have kept premiums low, making insurance more affordable for many. He stated, "Without the subsidies, premiums are just mechanically going to go up." Even if a vote occurs to extend the tax credits, Markowski expressed concern that any premium adjustments may not be reflected in time for the open enrollment period ending in mid-December.

Experts predict that if the enhanced tax credits expire, many individuals may disenroll from ACA plans due to rising premiums. This disenrollment is likely to be more pronounced among healthier individuals, which could lead to further increases in insurance premiums. Michael Sparer, chair of the department of health policy and management at Columbia University, explained, "If you've got some condition, even if you lose the subsidies, you're going to really do everything you can -- scrimp and save -- to try to come up with the extra money because you need insurance coverage."

The potential expiration of the enhanced tax credits could also have long-term effects on hospitals and healthcare providers. Markowski warned that uninsured individuals will still require care, leading hospitals to negotiate directly with patients or seek government funding. This situation could result in hospitals absorbing some of the costs, negatively impacting their financial stability.

In response to the potential expiration of the tax credits, Republicans have proposed alternative methods to help Americans lower healthcare costs. Former President Donald Trump suggested that the federal government could provide direct payments to individuals for purchasing health insurance instead of offering subsidies to insurers. However, Sparer cautioned that this approach could be costly for Americans, as they would be subject to taxes on these payments, unlike employer-provided insurance.

Sen. Bill Cassidy, R-La., recently proposed that eligible Americans could receive a pre-funded federal flexible spending account to cover health expenses. While Markowski acknowledged that this could provide individuals with more choices, he emphasized that it would not replace the need for insurance. "Insurance is mainly a means to protect individuals from financial harm because health care is expensive," he said.

In a related development, Congresswoman Julie Johnson, D-Texas, expressed her discontent with the recent bipartisan deal that ended the government shutdown. Johnson, who did not support the funding measure, stated that her constituents are upset about the potential loss of healthcare subsidies. "I think trading off healthcare for millions of people... was not a deal I was gonna make," she said, highlighting concerns about skyrocketing insurance premiums for families in her district.

As the situation unfolds, the fate of ACA subsidies and their impact on healthcare costs remains a critical issue for lawmakers and citizens alike.