Hospitals prep for rising ER visits as ACA subsidy lapse leaves patients with ‘impossible choices’

Hospitals and health systems nationwide are preparing for significant access and operational challenges after enhanced ACA premium tax credits expired Dec. 31 and congressional negotiations to revive them remain uncertain.

The House voted Jan. 8 to extend the subsidies for three years, but the measure is not expected to pass in the Senate. A bipartisan group of senators is instead advancing a narrower two-year proposal that would include new income limits, minimum monthly premiums and additional guardrails around enrollment. Legislative text could be finalized as soon as Jan. 12, but no immediate relief is guaranteed for hospitals planning for 2026.

Without an extension, health system leaders warn that emergency departments will see higher volumes, uncompensated care will rise and access gaps will widen — particularly in rural and underserved communities.

ED strain, coverage losses and rising uncertainty

Nearly 93% of the 24.3 million Americans enrolled in ACA marketplace plans in 2025 relied on enhanced subsidies, according to CMS. The Urban Institute estimates 4.8 million people could lose coverage without an extension.

“Americans continue to say affordable coverage matters. Families want stability and they want to know they can access care when they need it,” Ascension President and CEO Eduardo Conrado said in a Jan. 9 statement shared with Becker’s. “More than 20 million people are facing higher premiums or the loss of coverage altogether. For many of our patients, these tax credits are the difference between having insurance and delaying or going without care. Their expiration forces impossible choices between medical care and everyday necessities and increases the risk of medical debt.”

Hospital leaders argue the policy change will have systemwide ripple effects, including longer delays and wait times, especially in already overburdened emergency departments.

“We’re currently assuming the subsidies for the exchanges will go away, and that’s likely to increase uncompensated care,” Kyle Benoit, executive vice president and COO of Dover, Del.-based Bayhealth, said on a recent episode of the Becker’s Healthcare Podcast. “As a not-for-profit, community-based hospital, that will probably mean more activity in our ER. We have to care for these patients when they walk through our doors.”

Bayhealth is investing in fast-track emergency department areas and streamlining inpatient flow to prepare for higher volumes, but Mr. Benoit said waiting for political clarity is not a strategy.

“We have to stop hoping challenges will go away and instead focus on real opportunities to reduce the cost of care while staying accessible to our patients,” he said. 

Economic ripple effects extend beyond hospitals

The expiration of ACA subsidies is also expected to ripple across state economies. A Commonwealth Fund analysis projected a $57 billion drop in national economic output, a $34 billion decline in state GDPs and the loss of 286,000 jobs in 2026 — including 130,000 healthcare positions.

States projected to see the steepest coverage losses include Mississippi, South Carolina, Tennessee, Texas and Georgia, while Texas, Florida and Georgia would face the largest federal funding losses.

“With the tax credits expired, millions of hardworking Americans are now priced out of health coverage and need Congress to act,” Charlene MacDonald, president and CEO of the Federation of American Hospitals, said in a statement shared with Becker’s. “Real relief requires a bipartisan solution that extends the tax credits, lowers Americans’ health care costs, and can be signed into law.”

Calling the issue nonpartisan, Mr. Conrado also urged lawmakers to act.

“This is not about politics. It is about people. Extending these tax credits would help families keep coverage and ensure care remains available for the people who depend on it,” he said. “I ask congressional leaders to build on this bipartisan momentum and find a path forward that protects access to care and supports a healthier future for all.” 

As hospitals plan for a volatile 2026, leaders say clarity — and action — are urgently needed to prevent deeper access gaps, ED overcrowding and further strain on an already fragile healthcare safety net.

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