As health insurance costs rise, lawmakers remain undecided on who should pay for healthcare

December 15, 2025—the deadline for enrolling in a marketplace plan through the Affordable Care Act for 2026—came and went without an agreement on the federal subsidies that kept ACA plans more affordable for many Americans. Despite a last-ditch attempt in the House to extend ACA subsidies , with Congress adjourning for the year on December 19, it’s looking almost certain that Americans relying on ACA subsidies will face a steep increase in healthcare costs in 2026. As a gerontologist who studies the U.S. healthcare system , I’m aware that disagreements about healthcare in America have a long history. The main bone of contention is whether providing healthcare is the responsibility of the government or of individuals or their employers. The ACA , passed in 2010 as the country’s first major piece of health legislation since the passage of Medicare and Medicaid in 1965, represents one more chapter in that long-standing debate. That debate explains why the health law has fueled so much political divisiveness—including a standoff that spurred a record-breaking 43-day-long government shutdown , which began on October 1, 2025. In my view, regardless of how Congress resolves, or doesn’t resolve, the current dispute over ACA subsidies, a durable U.S. healthcare policy will remain out of reach until lawmakers address the core question of who should shoulder the cost of healthcare. The ACA’s roots In the years before the ACA’s passage, some 49 million Americans —15% of the population—lacked health insurance. This number had been rising in the wake of the 2008 recession . That’s because the majority of Americans ages 18 to 64 with health insurance receive their health benefits through their employer. In the 2008 downturn, people who lost their jobs basically lost their healthcare coverage. For those who believed government had a primary role in providing health insurance for its citizens, the growing number of people lacking coverage hit a crisis point that required an intervention . Those who place responsibility on individuals and employers saw the ACA as a perversion of the government’s purpose . The political parties could find no common ground—and this challenge continues. The major goal of the ACA was to reduce the number of uninsured Americans by about 30 million people , or to about 3% of the U.S. population. It got about halfway there: Today, about 26 million Americans , or 8%, are uninsured, though this number fluctuates based on changes in the economy and federal and state policy. Health insurance for all? The ACA implemented an array of strategies to accomplish this goal. Some were popular, such as allowing parents to keep their kids on their family insurance until age 26. Some were unpopular, such as the mandate that everyone must have insurance . But two strategies in particular had the biggest impact on the number of uninsured. One was expanding the Medicaid program to include workers whose income was below 138% of the poverty line. The other was providing subsidies to people with low and moderate incomes that could...

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