Real journalists wrote and edited this (not AI)—independent, community-driven journalism survives because you back it. Donate to sustain Prism’s mission and the humans behind it.

UPDATE [Dec. 14, 2025]: Since publication, the Senate has voted down both a Democratic bill to extend the Affordable Care Act’s enhanced premium tax credits and a Republican alternative that would have shifted aid into health savings accounts. As a result, the more generous subsidies are now expected to expire at the end of the year, and millions of enrollees are likely to face significant premium increases or lose coverage,including many disabled people who rely on ACA plans.

Joey Zeltner was working in IT at the Valley Hospital in Paramus, New Jersey, when she became disabled by a post-viral condition. Since 2019, she has suffered from dysautonomia, a condition that causes an abnormally high heart rate, dizziness, and debilitating fatigue, leaving her unable to work.

“I was super proud of my career,” Zeltner said. “And then I lost everything.”

When she lost her job, Zeltner also lost her employer-based health insurance. She was also rejected for state disability—which would give her access to Medicaid insurance—three times. 

A marketplace plan through the Affordable Care Act (ACA) was Zeltner’s only option for health insurance, so she bought a silver plan through Blue Cross Blue Shield.  

At the end of this year, however, the ACA’s enhanced subsidies are expiring unless Congress acts to extend them. Zeltner expected her monthly premiums to go from about $400 per month to around $650.

Zeltner’s situation is far from unique. The vast majority of the 24 million people who get insurance through the ACA marketplace receive some kind of subsidy to help cover the high cost of monthly premiums for their plans, which are still difficult for most people to afford. For the millions of disabled people who rely on the marketplace for health insurance, the threat of losing the subsidies is especially stark. Disabled people tend to need more comprehensive health coverage and higher-tier, more expensive plans. They are also more likely to be self-employed for more flexibility and therefore, don’t get insurance through an employer, and many are unable to meet stringent state disability requirements. 

While Zeltner does receive long-term disability payments from her former employer, affording health care is already difficult. She lives with her ex-partner because she said she cannot afford to live alone. She does not know where she will find the additional cash to pay for her health insurance, which can be a life-and-death situation for people with disabilities.

“If I don’t have the medications that I’m on to help control my heart rate and my blood pressure, I very well could have a stroke or a heart attack,” Zeltner said. 

Attacks on health coverage

In 2021, amid the height of the COVID-19 pandemic, the Biden administration established enhanced premium tax credits to help people pay for their health insurance through the ACA marketplace, which expanded eligibility to allow many more enrollees to receive discounts on their monthly payments. Health policy research think tank KFF found that more than 84% of marketplace enrollees—including almost all Democrats and nearly three-quarters of Republicans—say that Congress should extend the tax credits. Without the tax credits, subsidized enrollees could see their insurance rates increase an average of 114%. 

The outcome “will be devastating in ways that I don’t even know we can anticipate in this moment,” said Dom Kelly, the founder and CEO of advocacy group New Disabled South.  

These credits are critical amid an ongoing affordability crisis, and insurers are also raising rates. Extending the credits was the linchpin of the 40-day government shutdown that ultimately ended in November in a stalemate when a group of Democrats voted to reopen the government without a guarantee that the credits would be extended.  

The end of the subsidies is part and parcel of Republican lawmakers’ ongoing effort to destroy the ACA, which they significantly weakened during President Donald Trump’s first term, explained Mia Ives-Rublee, senior director of the Disability Justice Initiative at the Center for American Progress. The ACA is especially critical for disabled people because it makes discrimination against people with “underlying conditions” illegal, expands eligibility for Medicaid, and allows people to stay on their parents’ insurance until age 26.

In addition to the end of the subsidies, Trump’s spending bill passed earlier this year makes other changes to the ACA that will make it more difficult to maintain coverage, including defunding health care navigators that help enrollees register for a plan and barring some immigrants, including Deferred Action for Childhood Arrivals recipients, from signing up for ACA plans. This will disproportionately impact Black people—who are more likely to be disabled—rural populations, and adults ages 50 to 64, according to the Bipartisan Policy Institute. 

This also comes as massive Medicaid cuts are set to take effect at the end of 2026, which will cause millions to lose their health insurance. It also comes amid the end of diversity, equity, and inclusion programs that helped address health care disparities, as well as cuts to the Department of Veterans Affairs, which serves a disproportionate number of disabled people. Meanwhile, an ongoing assault on public health puts disabled and immunocompromised people particularly at risk. 

Rationing health care

With the end of subsidies, a third of ACA enrollees are considering registering for lower-tier plans, according to KFF. This will likely increase out-of-pocket costs as patients—especially those who have more health care needs—are forced to go out-of-network to obtain quality care. 

“People who don’t have the resources often buy the lowest plan possible, which means more out-of-pocket expenses, which can still cause people to go bankrupt,” said Ives-Rublee.

But for disabled people like Zeltner, going on a lower-tier plan that wouldn’t cover her prescriptions and doctors isn’t an option. “If I lost my prescription coverage, I could die,” she said. 

Kelly, of New Disabled South, underscored that even now, many insurance plans do not cover much of the care disabled people need, including durable equipment and mobility devices such as wheelchairs. For people with rare conditions like Zeltner’s, accessing specialists in-network can also be extremely difficult, especially because ACA plans only cover in-state doctors. 

Though the ACA is not without its flaws, Ives-Rublee said, it provides another option for insurance for disabled people who don’t qualify for state disability insurance or Supplemental Security Income. 

Proving disability to the government is notoriously difficult and often requires the assistance of a lawyer to appeal rejections, which is unaffordable to many. The number of people applying for disability has also spiked since the beginning of the COVID-19 pandemic, with millions suffering from post-COVID conditions. But the Trump administration plans to make cuts to the Social Security Disability Insurance program too.

With even fewer options for affordable health care, people will likely be forced to ration care and medications, such as insulin, and some might have to forego insurance entirely. According to KFF, a quarter of ACA enrollees plan to go without insurance next year if the subsidies end. 

The impact of ending the subsidies, alongside the myriad other attacks on health care access, is hard to overstate, according to Kelly. 

“We will see long-term damaging impacts to people’s health and really devastating loss of life, as people have to make really terrible choices about their health care that no one should have to make,” he said.

Increasing the costs of health care for the people who need it most is “eugenics policy,” Kelly said. 

As it is, some 65,000 people go into bankruptcy because of medical bills, with medical debt accounting for the majority of personal bankruptcies in the U.S.. The end of ACA enhanced subsidies would likely increase those numbers. 

In states with the budget and political will, some of the damage could be reversed through state-level policy, said Kelly. Meanwhile, Ives-Rublee stressed the importance of calling lawmakers to extend the subsidies, even though, she said, that tactic doesn’t seem to be moving elected officials thus far. 

In the disabled community, particularly, said Zeltner, “We’re not feeling like we’re being heard, because we can’t get out there and make our voices heard.”

Editorial Team:
Sahar Fatima, Lead Editor
Carolyn Copeland, Top Editor
Rashmee Kumar, Copy Editor