Congress returned home again, leaving behind a familiar mess. Health care costs are rising, insurance premiums are rising, millions of people are struggling to maintain insurance, and yet again, lawmakers have failed to act. This is not surprising. These council cowards love to run and hide, always leaving unfinished business, and their cowardice has consequences.
Health care consumes approximately 17 to 18 percent of the U.S. gross domestic product, far more than any other wealthy nation. We spend nearly one in every five dollars of our economy on health care, yet our outcomes in terms of life expectancy, maternal mortality, and chronic disease management are among the worst in the developed world. This disconnect is no accident. It is the result of policy choices, including the choice to do nothing.
One of the most obvious examples is Congress' failure to extend the Affordable Care Act's (ACA) enhanced premium tax credit, sometimes misleadingly referred to as the “Obamacare subsidy.” These credits lowered monthly premiums for people who purchased insurance through the Health Insurance Marketplace. During the pandemic, Congress expanded the insurance system to make it more affordable for millions of working and middle-class households, including seniors, gig workers, and the self-employed who are not yet eligible for Medicare.
These enhanced credits have expired. Not because they didn't work, but because Congress (including Democrats) chose not to update them. The results were immediate and predictable. Insurance premiums have increased significantly in some cases. For some families, monthly expenses increased by hundreds of dollars. Many responded the only way they could: by lowering coverage, taking on higher deductibles, or eliminating insurance altogether. Coverage didn't disappear overnight, it just became more affordable.
This is important not only for individual households but also for the health system as a whole. When people lose affordable insurance, they delay treatment. Preventable conditions worsen. Emergency rooms absorb more free care. Hospitals, especially rural and safety-net hospitals, face greater financial burdens. Costs are shifted, not reduced.
And, as always in the United States, the burden falls unevenly.
Health disparities are not just a biological or behavioral problem. They are about access, affordability, and policy design. Black and Latino households were already more likely to be uninsured or underinsured and were disproportionately affected by premium increases. Seniors, ages 50 to 64, who are too young for Medicare but often face higher health risks, were especially hard hit. People with chronic conditions faced higher out-of-pocket costs and smaller provider networks.
Geography further complicates matters. Healthcare is still largely controlled by state, so access and affordability vary widely depending on where you live. States that rejected Medicaid expansion under the ACA continue to have higher uninsured rates and worse outcomes. Rural areas are facing hospital closures and a shortage of health care providers. In fact, Americans use different health care systems depending on their zip code.
This fragmentation is costly and inefficient. Negotiation power with pharmaceutical companies and insurance companies will be weakened. A huge amount of administrative waste occurs. and normalize inequality as a feature rather than a failure of the system.
Congressional inaction also reinforces the growing recognition that medical insecurity is something that individuals must deal with alone. That framework is wrong. Healthcare is more than just a personal expense. It's economic infrastructure. It affects the labor market, retirement decisions, household finances, and long-term productivity. Medical debt remains one of the major sources of financial stress for American households, even for insured households.
What makes this moment particularly troubling is that we know what will work. Other wealthy countries negotiate drug prices. These provide universal baseline coverage. They invest in primary care and prevention. Achieve better results at lower costs. The United States is not without technological solutions. Political will is lacking.
Letting the enhanced ACA tax credits expire was not inevitable. It was a choice that lowered health care affordability, widened inequality, and destabilized coverage for millions of people. Congress went home without a medical system in place, but it did not result in an adjournment.
Health policy is often discussed in terms of abstract concepts such as budgets, subsidies, and market dynamics. But essentially it's about who can access care, when, and at what cost. When Congress chooses delay rather than action, inequality bridges the gap.
A system this big, this expensive, this unequal will not fail silently. It takes a toll on your body, your budget, and your life. And every time a member of Congress resigns, Americans will have to pay more for less.
Dr. Julian Malveaux is an economist and author based in Washington, DC.
