For the past few weeks, Shana Verstegen has been "sick to her stomach" wondering what might happen to her family's health insurance next year.
By Madeline Halpert
Ms Verstegen and her husband both work for a small business as fitness trainers, meaning they have to pay for their own plan.
The Wisconsin parents of two have saved an estimated $800 (£601) a month on their health insurance through Affordable Care Act, also known as Obamacare, premium tax credits.
Set to expire at the end of the year, the federal subsidies are now at the heart of the battle over the US shutdown. Democrats will not back a spending deal that reopens the government unless Republicans renew the subsidies.
Ms Verstegen and others are watching anxiously, wondering what kind of financial consequences they would face if a deal can't be reached.
"Everything's getting more expensive now anyway, and this would be another major hit for our family," she said.
Health policy experts say time is running out to prevent millions from losing their health insurance because the price hikes will make it unaffordable.
The tax credits were first introduced through former President Barack Obama's Affordable Care Act (ACA) in 2014 and then expanded during the Covid pandemic.
Some Americans could see their monthly cost of insurance - also known as a premium - rise by hundreds of dollars on 1 November, said Leighton Ku, a health policy professor at George Washington's Milken Institute School of Public Health.
"If you are one of the 20 or so million people who's getting your health insurance through the marketplace, if you're about to see prices on average double, that's a big deal," he said. "It's going to be too late real soon."
Red states would be hardest hit
Of the roughly 24 million people who get their health insurance through the ACA Marketplace, a vast majority benefit from the premium subsidies.
Stacy Cox, a photographer in Utah, has saved over $10,000 a year on average since she started benefiting from the subsidies in 2022.
"It is an absolute lifeline for so many of us," said Ms Cox, who has an autoimmune disease.
But if the tax credits are not extended, Ms Cox said she will have to quit her newly launched photography business and find a different job that provides health insurance.
Around seven million people like Ms Cox are expected to stop buying health insurance through the marketplace if the tax credits end, Ku said. Of those, around four to five million are expected to lose health care coverage altogether because they won't be able to find other means, data suggests.
Many of those who will be affected are working-class people who don't qualify for Medicaid, the government-run programme which provides healthcare insurance for low-income adults, children, pregnant women, elderly adults and people with disabilities.
The hardest hit could be those in 10 US states - most of which vote Republican - that have chosen not to expand eligibility for Medicaid.
"One of the political paradoxes of all this is that the places that get hurt the most are states that are more conservative," said Ku.
If the subsidies expire and healthier people begin to opt out of insurance, that will also raise premium prices overall for Americans, as a sicker pool of customers will drive up healthcare costs, said Elizabeth Fowler, a distinguished scholar at Johns Hopkins Bloomberg School of Public Health.
"You start to get into a death spiral where premiums become even more expensive and more out of reach for more people," she said.
Divisions emerge among Republicans
Some Republican leaders in Congress have maintained they will discuss the future of subsidies once the government reopens.
But at least a few Republicans want their party to take action now.
Representative Marjorie Taylor Greene, a close ally of President Donald Trump's, has said she is in favour of the tax credits, adding that her own children's premiums would go up if they end.
"I'm absolutely disgusted that health insurance premiums will DOUBLE if the tax credits expire this year," the Georgia lawmaker said.
Republican Senator Lisa Murkowski this month introduced a bill to extend the credits for two years, while Senators Dan Sullivan and Tommy Tuberville are also in support.
Trump appeared open to negotiating with Democrats over their health care agenda, saying last Monday that if it's "the right deal, I'd make a deal". But he seemed to walk back those remarks later.
Experts said Republicans' opposition to the subsidies is representative of their general dislike of the ACA, also known as Obamacare.
"Some of it has to do with the belief that it's big government intrusion, and so they resent it for that," Ku said.
In addition to the expiration of the tax credits, Republicans were also able to target the ACA this year through Trump's tax and spending bill, which made steep cuts to Medicaid, changes Democrats are also seeking to reverse.
Republicans argue those cuts are aimed at eliminating waste, fraud and abuse of federal funding.
Time ticking to save subsidies
The deeper cuts to Medicaid are not expected to take effect for years but the Democrats who want the healthcare premiums to stay at current levels have to race against a looming deadline - the 1 November open enrollment period.
Some Republicans have argued that the subsidies can be resolved later since they only expire at the end of the year, but Ku said some health insurers have already changed their rates in response to the expiration, and may not be able to change them.
"The mechanics of fixing this problem this late in the game are complicated," Ku said.
Ms Verstegen said if her rates go up, her family will have to make financial sacrifices. Her family already has a deductible of $14,000, and she is still paying back a major hip surgery from two years ago.
"I truly believe that if this goes away next year, a lot of people are going to be very upset, and that'll show up in elections," she said.
Health care affordability was not a top issue in 2024 or other recent elections, as Americans have grown accustomed to accessing health insurance through the ACA.
But if people start to see their insurance prices rise, especially in red districts, that could prove a political liability for the Republican Party, Ku said.
"If I were a representative from Texas or Georgia, I would be feeling some doubts," he said. "But in a game of chicken, you never want to show your doubts."
If the subsidies are not renewed before November, people will make their insurance decisions assuming their premiums are set to double, even if the credits are renewed at a later date.
