TYLER, Texas (AP) — Celia Monreal worries every day about the cartilage loss in her husband’s knees. Not just because it’s hard for her to see him in pain but also because she knows soon their health care costs could skyrocket.

Monreal, 47, and her husband, Jorge, 57, rely on the Affordable Care Act marketplace for their health coverage. If Congress doesn’t extend certain ACA tax credits set to expire at the end of the year, their fully subsidized plan will increase in cost, putting it out of reach. Without insurance, they won’t be able to afford his expected knee replacement surgeries, much less the treatment they need for other issues, like her chronic high blood pressure and his high cholesterol.

“It worries me sometimes, because if you’re not healthy, then you’re not here for your kids,” Monreal said. “It’s a difficult decision, because, OK, do I spend $500 on a doctor’s visit or do I buy groceries?”

These are the types of choices facing millions of Americans whose state or federal marketplace health insurance plans will be up for renewal in November. The enhanced premium tax credits that have made coverage more affordable for low and middle-income enrollees for the past four years will expire this year if Congress doesn’t extend them. On average, this will more than double what subsidized enrollees currently pay for premiums next year, according to an analysis by health care research nonprofit KFF.

The tax credits are at the heart of the federal government shutdown, now in its third week with no end in sight. Democrats have demanded the subsidies be extended as part of any funding deal they negotiate, while Republicans insist they’ll only discuss the issue once the government is funded.

With Congress deadlocked and the open enrollment period for ACA plans approaching on Nov. 1 in most states, Americans like Monreal are left to navigate the unknown.

No extension will mean higher premiums for millions

More than 24 million people have ACA health insurance, comprising farmers, ranchers, small business owners and others who work in roles without health insurance options through their employers.

The enhanced premium tax credits set to expire this year have made costs far more manageable for many, allowing some lower-income enrollees to access health care with no premiums, while higher earners pay no more than 8.5% of their income.

If the tax credits expire, annual out-of-pocket premiums are expected to increase by 114% — an average of $1,016 — next year, per the KFF analysis.

While some premium tax credits will remain, the overall support will decrease for most enrollees. Anyone earning above 400% of the poverty level—around $63,000 a year for an individual—won’t qualify for the remaining tax credits.

According to experts, this will disproportionately affect both higher earners who face significant increases without extra subsidies and a significant number of lower earners who will see small, yet impactful hikes. Cynthia Cox, vice president and director of the ACA program at KFF, highlights that reduced subsidies will likely prompt some to drop health insurance entirely. This drop in coverage among younger, healthier individuals may lead to more significant costs for those remaining in the risk pool.

Moreover, hospitals might face strains from an increased number of uninsured patients seeking emergency care, potentially resulting in more hospital closures or additional cost increases.

“If you have less subsidy for people getting health insurance, you’re going to have less health coverage and less health care,” said Jason Levitis, a senior fellow at the Urban Institute. “The outcome will be sicker individuals and increased mortality rates.”

A caregiver wrestles with potential crises. Erin Jackson-Hill in Anchorage, Alaska, manages allergies, asthma, and worsening hip pain while waiting for a hip replacement. With ACA subsidies potentially disappearing, she feels ill-equipped to afford health insurance next year.

Despite already spending nearly $500 monthly for her premiums, she fears having to pay out of pocket for her medications if she drops coverage. “I will have to go to the emergency room or go bankrupt to afford treatment,” she remarked.

Similarly, Stan Clawson, a freelance filmmaker and adjunct professor from Salt Lake City, anticipates securing coverage even if it necessitates sacrificing grocery budgeting or finding employment that offers benefits.

Vivacious yet challenged, Clawson, who sustained a spinal cord injury that requires him to manage specific medical costs, stresses that without insurance, his financial stability would crumble under the weight of his medications alone, which could reach about $1,400 without coverage.

Finally, Chrissy Meehan, a hairstylist from Upper Chichester, Pennsylvania, who has a neck condition requiring surgery, expresses frustrations over the impending subsidy expiration and the heightening costs of healthcare. “I don’t want free; I just want affordable,” she said. “I work hard, and I want to do my part.”

Even if Congress does extend, the delay could carry consequences

Health policy experts caution that even if subsidies extend, insurance costs for 2026 are already projected higher, as insurers adjusted their rates in anticipation of potential subsidy expiration.

In addition, delays might introduce chaos and anxiety for families navigating the insurance landscape. Many have started receiving notices warning of impending premium hikes for the coming year.

As Levitis from the Urban Institute added, “If individuals opt out of coverage, it would be challenging to return them to the system.”

Monreal’s husband is expected to need knee replacements, further complicating their financial situation as they juggle their $45,000 annual income and care for their five children.

The uncertainty regarding health coverage has left Monreal deeply concerned as the ACA enrollment period draws near. “They haven’t informed us of anything,” she lamented, “and in the end, you could end up with no healthcare at all.”

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Swenson reported from New York. Associated Press video journalist Tassanee Vejpongsa contributed to this report.