Clock runs down on ACA subsidies as families brace for rising health-care costs

One of Virginia’s federal lawmakers and advocates on Wednesday renewed their warnings that allowing enhanced Affordable Care Act subsidies to expire at the end of the year would drive up premiums and push thousands of Virginians off their coverage, forcing families to choose between insurance and basic necessities.

On a press call hosted by Protect Our Care, U.S. Rep. Jennifer McClellan, D-Richmond, underscored those stakes by recalling the day her daughter was born nine weeks early — a medical emergency she said she only survived financially because she had insurance.

“Ten years ago, my daughter Samantha was born by emergency C-section when my placenta ruptured, and we both nearly died,” McClellan said. Samantha spent six weeks in the NICU, and because she had employer-provided insurance, McClellan said she could focus on recovery “without having to worry about how I was gonna pay those costs.”

That experience, she added, is why she pushed to expand Medicaid and establish Virginia’s state-based exchange as a state legislator — to ensure that “every pregnant woman had the ability to have insurance, so that she could have a healthy pregnancy, a full-term birth, and a healthy child.”

She warned that maternal and infant health outcomes are already worsening. 

“The United States has one of the highest pre-term birth rates in the world,” she said, citing the March of Dimes 2025 scorecard, which again gave the country a D-plus and reported that 10.4% of babies were born preterm. 

Virginia’s rate rose from 9.8% to 10.1%, and “three cities in Virginia earned an F — Virginia Beach, Norfolk, and Richmond,” McClellan said. 

She emphasized that these statistics “are likely going to get worse” as millions face losing coverage from major Medicaid cuts and the expiration of ACA subsidies. If the credits lapse, McClellan said, “106,000 Virginians will drop out of the marketplace, and 47,000 are estimated to remain uninsured, because they won’t be able to get insurance for other needs.”

Families will be forced into impossible decisions, she added. Many pregnant women “will choose to forego prenatal care… because they’ll be forced to choose between health insurance, paying rent, and paying their utility bills.” 

No parent plans for a premature birth, McClellan added: “I certainly didn’t. But it can happen to anybody. We need to make sure that those families are insured. Preterm birth is preventable, but we have to make sure that moms are healthy before they get pregnant and can get the care that they need.”

As costs rise, so do risks

The ACA’s enhanced premium tax credits have made coverage more affordable for millions since 2021. In Virginia, roughly 400,000 people use the marketplace, and as many as 100,000 could fall off their plans if the credits expire.

Health-care leaders have called the potential fallout “a bit of a tsunami,” warning that premiums could rise 30% to 50% next year.

Advocates on Wednesday’s call said the effects go far beyond monthly bills. 

Deneen Evans, a licensed clinical social worker from Roanoke County who earned a PhD, said her daughter was born prematurely with a severe brain hemorrhage requiring a shunt and months of NICU care. 

“These are lifelong challenges,” she said. Without stable insurance, “these children grow into adults with chronic medical issues.”

Kristen Clardy, a former Virginian now residing in Washington, D.C., said her son’s premature birth generated about $130,000 in medical bills — all covered by insurance. 

Later, marketplace coverage was “actually pretty affordable,” she said, until premiums began to spike. Now she faces an $800 to $900 monthly increase. “My heart breaks for moms who are having to make that choice between healthcare coverage and putting food on the table or gas and keeping their lights on,” Clardy said.

At the federal level, the question is whether to renew the enhanced ACA subsidies. President Donald Trump has urged Republicans not to extend them, arguing in a Nov. 18 Truth Social post that they “only benefit insurance companies,” Axios reported Tuesday. 

Instead, Trump and some GOP lawmakers have floated alternatives, including directing assistance to health-savings accounts or allowing cheaper, less comprehensive plans. Those concepts are currently being drafted into proposals. 

Democrats in Congress — including McClellan — and some Republicans argue the credits must be renewed before year’s end. The debate has become intertwined with broader budget negotiations that resulted in the longest federal government shutdown in the nation’s history. 

The ripple effect in Virginia

If Congress allows the subsidies to lapse, premiums could jump sharply for families on the exchange. 

Kenda Denia, founder of Birth in Color, said the consequences would fall hardest on Black mothers. She noted Black women are more than twice as likely to die from childbirth as white women, and Black babies are 57% more likely to be born preterm. 

“Approximately 52,000 people lost health insurance between 2023 and 2024, including around 11,500 children,” she said. Without coverage, “fewer expecting moms are getting the prenatal care that they need.”

Maternal mental health advocates also warned of cascading effects. 

Amy Hammond, executive director of Postpartum Support Virginia, said pregnant people with mental health conditions are 50% more likely to give birth prematurely, and mothers of NICU babies have up to a 70% risk of postpartum depression. 

She said higher premiums “are a barrier to accessing adequate care before, during, and after pregnancy, which ultimately cost taxpayers more.”

Families at the breaking point

For families living paycheck to paycheck, the fight in Washington translates directly into skipped appointments and strained budgets. Clardy said parents like her feel trapped between necessity and affordability. “Those are the real decisions that people are faced with right now,” she said.

Meanwhile, Virginia’s marketplace is already bracing for instability. Some insurers, including Aetna, plan to exit next year, citing uncertainty tied to the subsidies. Nationally, as many as 17 million Americans could lose coverage under Trump-aligned proposals that allow the subsidies to expire,

With the enhanced subsidies set to end Dec. 31, lawmakers say time is running short. 

“Millions more are about to see their health insurance premiums spike beyond their ability to afford when the enhanced premium tax credits under the ACA expire at the end of this year,” McClellan said. ”As a result, the cost of insurance will go up for everybody else.”

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