Instead of passing a budget, the United States Congress allowed the government to shut down on October 1, 2025 and has been shut down since. When government shutdowns take place, the federal government limits services and ceases non-essential operations. This is not the first time such a shutdown has occurred. The longest shutdown took place during Trump's first administration in 2018-19 over funding for expanding barriers on the U.S.-Mexico border. The 1995-1996 shutdown under the Clinton administration was over spending cuts, whereas the 2013 shutdown during the Obama administration was about the implementation of the Affordable Care Act (ACA). While commonly referred to as the ACA, I prefer calling it Obamacare over the ACA because the ACA did nothing to make healthcare more affordable (see here and here), but we can call it ACA for shorthand purposes.
Interestingly enough, the lack of affordability under ACA brings us to today because the current shutdown is primarily about ACA. During the COVID pandemic, Congress passed the American Rescue Plan, which included a temporary expansion of the ACA's premium tax credits (PTCs) to help soften the blow of the COVID pandemic. These tax credits, which account for 7 percent of the Americans who use the Obamacare-run insurance marketplace, had these tax credits extended under the Inflation Reduction Act in 2022. There is nothing permanent like a temporary government measure, right? Because now, the Democrats want to extend the Biden-era tax credits yet again, even though the COVID pandemic ended a few years ago. Democrat's commitment to extending the Biden-era tax credits was strong enough that they refused to pass a budget without them. Let us get into why this insistence to maintain the PTCs is short-sighted and make matters worse.
It is a common talking point from proponents to say that the premiums will more than double if the PTCs expire. While technically true, the claim is also misleading. The PTCs act as a demand-side subsidy, which both artificially increase price and quantity consumed. Consumers are paying less for out-of-pocket premiums, but it does not mean the total cost of healthcare has decreased. The subsidies, in fact, shift the cost from the individual enrollee to the taxpayer, a distinction that often involves the same individuals. People think it is cheaper because someone else is footing the bill. It is not about making healthcare cheaper, but it is a matter of budgetary sleight-of-hand.
This subsidy is a classic economic distortion that functions similarly to the employment sponsored insurance tax credit. Since the subsidies scale with premiums, enrollees are insulated from rising costs, while taxpayers bear the increased burden indirectly. As a result, it encourages overinsurance, thereby reducing market discipline and increasing overall healthcare costs because insurers have less pressure to compete on price, thereby creating an upward price spiral (e.g., Cannon, 2022; Powell, 2012).
The PTC subsidy fuels premium growth, which in turn raises subsidy payments further. The ACA did not contain premium costs. If anything, individual premiums increased much faster than medical care or overall prices since the ACA was written back in 2009. Individual premiums increased by 143 percent compared to 52 percent of medical care costs and 49 percent for overall consumer prices. Here is data from the Center for Health and Economy showing how ACA premiums have increased over time. As a result, healthcare costs rose in a similar way that federal subsidies to college tuition have caused tuition costs to skyrocket. Even before the pandemic and this PTC expansion, ACA premiums had already doubled, despite Obama's promises of family savings.
What the PTC subsidies do to make the matter worse is that it lowers price sensitivity. Consumers have less incentive to shop around or demand lower-cost care, which undermines competition and encourages inefficiency. This distorts consumer choice signals, creates a moral hazard, and makes healthcare inflation all the worse. Much like I asked last May with regards to Medicaid, what good does it do to fund an insolvent and unsustainable program?
In addition to the economic theory and reality of demand-side tax credit, expanding the tax credits will not fix the system. It will merely hide their failures behind market distortion and more debt. Speaking of debt, the Congressional Budget Office (CBO) estimated last month that extending the PTCs will cost $350 billion over the next decade. Combined with the corresponding interest costs of $60 billion, that brings the total cost to $488 billion over the next decade. This is close to the Paragon Health Institute's estimate of $450 billion.
To put this into context, the PTCs cover 3.8 million enrollees, which would put the per enrollee cost for the premiums at around $13,000. This is crazy because the average spend for all healthcare per person (not only the premiums) is at around $14,000, according to the Centers for Medicare and Medicaid. If those on Obamacare under the PTCs are spending almost the same amount on premiums alone than the average American spends on overall healthcare, this is hardly an efficient or sustainable use of taxpayer dollars.
To make matters worse, the legislation for the PTCs removed the 400% of poverty line cap, which means that a large share of subsidy dollars are going to higher-income households. The Cato Institute found that a third of those receiving insurance with these PTCs are above the 400% threshold. Similar to student loan forgiveness, these tax credits go to households that are, on average, better equipped to handle their finances, thereby questioning fairness of the PTCs. If you are arguing now that those at this threshold need subsidies, it is another reason showing us how the ACA has failed at making healthcare more affordable.
This systemic instability is the sort of phenomenon that makes Obamacare even more unsustainable than it was pre-pandemic. As the Tax Foundation argues, the PTCs are a symptom of showing how federal subsidies and tax preferences in healthcare have increased the cost of healthcare, as well as how the healthcare industry is the most subsidized in the United States. The PTCs are another example of how the top-down model of the ACA has failed the everyday American spectacularly.
The fight is ultimately not about coverage per se, but how far the government is willing to fund a broken system, a question that could also be asked about Social Security. These COVID-era credits were sold as temporary relief during an emergency. The emergency is long over, but the spending remains. This is hardly a new phenomenon. The Cato Institute calculated that at least $12.5 trillion has been spent on emergency spending since 1991. This also shows why the government needs to stop declaring emergencies to continuously expand government largesse into insolvency. As Milton Friedman once quipped, "nothing is so permanent as a temporary government program," and the PTCs are proving the rule.
The enhanced PTCs do not lower costs, but instead masks the cost increases. Instead of helping the vulnerable, they increasingly benefit higher-income households. Instead of fostering competition, they entrench price-insensitive behavior while rewarding the healthcare insurance industry with corporate welfare. And these premiums come at a cost that exceed the average cost of all healthcare spending. These PTCs are fiscal malpractice disguised as compassion. Do not get me started on how the ACA as a whole increases healthcare costs while receiving less care and fewer options. As I wrote last year, Obamacare has unsurprisingly fulfilled its promises, especially the one about more affordable healthcare.
In the short run, the PTC expansion under the Inflation Reduction Act should expire because pretending that the PTCs make healthcare more affordable is a dangerous illusion. If we are going to have any serious conversation about how to make the quality of healthcare bette while lowering costs, Congress needs to stop doubling down on the very policies that make the problem of skyrocketing healthcare costs a problem in the first place. I am not going to waste my time to highlight real reform if lawmakers cannot take that first step of recognizing that endlessly expanding subsidies masks the systemic failures that they think they are fixing. First, Congress needs to end the PTC expansion and recognize the role that these subsidies play in artificially increasing healthcare costs. Then we can talk real reform.
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