Esta directiva, incluida en un cable enviado por el Departamento de Estado a funcionarios de embajadas y consulados —y revisada por KFF Health News— indica a los oficiales encargados de los visados declarar a los solicitantes “no elegibles” para ingresar a Estados Unidos por nuevas razones, entre ellas la edad o la probabilidad de que fueran a depender de beneficios públicos.

También dice que estas personas podrían convertirse en una “carga pública”, es decir, representar un posible gasto para los recursos del país debido a sus problemas de salud o a su edad.

Si bien la evaluación del estado de salud de potenciales inmigrantes ha sido parte del proceso de solicitud de una visa durante años —incluyendo pruebas para detectar enfermedades transmisibles como la tuberculosis y la revisión del historial de vacunas—, expertos dijeron que las nuevas directrices amplían considerablemente la lista de afecciones médicas a considerar. Y otorgan a los oficiales más poder para tomar decisiones sobre inmigración basadas en la salud del solicitante.

La directiva forma parte de la campaña divisiva y agresiva de la administración Trump para deportar a personas que viven en el país sin papeles y desalentar a otros a emigrar.

La ofensiva del gobierno para restringir la inmigración ha incluido arrestos masivos a diario, prohibiciones para refugiados de ciertos países y planes para limitar drásticamente la cantidad total de inmigrantes permitidos en el país.

Las nuevas directrices exigen que la salud de los inmigrantes sea un tema central en el proceso de solicitud.

Aunque se aplican a casi todos los solicitantes de visa, probablemente se utilicen sobre todo en los casos de personas que quieran residir en el país de manera permanente, explicó Charles Wheeler, abogado principal de Catholic Legal Immigration Network, una organización sin fines de lucro que ofrece asistencia legal.

“Se debe considerar la salud del solicitante”, dice el cable. “Ciertas afecciones médicas —incluyendo, pero no limitándose, a enfermedades cardiovasculares y respiratorias, cáncer, diabetes, enfermedades metabólicas, enfermedades neurológicas y trastornos de salud mental— pueden requerir atención médica que cuesta cientos de miles de dólares”.

Cerca del 10% de la población mundial vive con diabetes. Las enfermedades cardiovasculares también son comunes y son la principal causa de muerte a nivel global.

El cable también anima a los oficiales encargados de las visas a considerar otras afecciones como la obesidad, que se destaca que puede causar asma, apnea del sueño e hipertensión, al evaluar si una persona podría convertirse en una carga pública. Si se concluye que esto pudiera ocurrir, podría negársele la entrada a Estados Unidos.

“Todas estas [afecciones] pueden requerir atención médica costosa y a largo plazo”, afirma el cable. Los voceros del Departamento de Estado no respondieron de inmediato a una solicitud de comentarios.

Los oficiales también deben determinar si los solicitantes cuentan con medios económicos suficientes para cubrir el costo de su atención médica sin ayuda del gobierno de Estados Unidos.

“El solicitante, ¿cuenta con recursos financieros adecuados para cubrir esos gastos durante toda su vida, sin recurrir a asistencia económica pública o sin requerir institucionalización a largo plazo a expensas del gobierno?”, dice el cable.

Según Wheeler, el lenguaje del cable parece contradecir al propio Manual de Asuntos Exteriores del Departamento de Estado, que indica que los oficiales no pueden rechazar una solicitud basándose en escenarios hipotéticos.

La directiva dirige a los oficiales a “desarrollar sus propias opiniones sobre lo que podría derivar en una emergencia médica o en costos médicos futuros”, dijo. “Eso es preocupante porque no tienen formación médica, no tienen experiencia en este ámbito y no deberían hacer proyecciones basadas en su conocimiento personal o en prejuicios”.

La guía también pide a los oficiales considerar la salud de los familiares del solicitante, incluidos hijos o padres mayores.

“¿Alguno de los dependientes tiene discapacidades, enfermedades crónicas u otras necesidades especiales que requieran atención al grado de impedir que el solicitante mantenga un empleo?”, dice una pregunta del cable.

Actualmente, los inmigrantes ya deben someterse a un examen médico realizado por un doctor aprobado por una embajada estadounidense.

Se les evalúa para detectar enfermedades transmisibles, como tuberculosis, y se les pide llenar un formulario donde informen si han tenido antecedentes de consumo de drogas o alcohol, afecciones de salud mental o episodios de violencia. También deben tener una serie de vacunas contra enfermedades infecciosas como el sarampión, la polio y la hepatitis B.

Pero esta nueva directiva va más allá, al recalcar que se deben tomar en cuenta las afecciones crónicas, explicó Sophia Genovese, abogada de inmigración en la Universidad de Georgetown. También señaló que el lenguaje de la directiva alienta a los oficiales y a los médicos encargados de examinar a los solicitantes a especular sobre el costo de su atención médica y su capacidad de obtener empleo en Estados Unidos, dadas sus condiciones de salud.

“Tomar en cuenta los antecedentes de diabetes o de enfermedades cardíacas, eso es bastante amplio”, dijo Genovese. “Ya existe cierto grado de evaluación, pero no tan amplio como para opinar sobre, por ejemplo, ‘¿Qué pasa si alguien sufre un shock diabético?’ Si este cambio se aplica de inmediato, obviamente causará muchos problemas cuando las personas se presenten a entrevistas consulares”.

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The guidance, issued in a cable the State Department sent to embassy and consular officials and examined by KFF Health News, directs visa officers to deem applicants ineligible to enter the U.S. for several new reasons, including age or the likelihood they might rely on public benefits. The guidance says that such people could become a “public charge” — a potential drain on U.S. resources — because of their health issues or age.

While assessing the health of potential immigrants has been part of the visa application process for years, including screening for communicable diseases like tuberculosis and obtaining vaccine history, experts said the new guidelines greatly expand the list of medical conditions to be considered and give visa officers more power to make decisions about immigration based on an applicant’s health status.

The directive is part of the Trump administration’s divisive and aggressive campaign to deport immigrants living without authorization in the U.S. and dissuade others from immigrating into the country. The White House’s crusade to push out immigrants has included daily mass arrests, bans on refugees from certain countries, and plans to severely restrict the total number permitted into the U.S.

The new guidelines mandate that immigrants’ health be a focus in the application process. The guidance applies to nearly all visa applicants but is likely to be used only in cases in which people seek to permanently reside in the U.S., said Charles Wheeler, a senior attorney for the Catholic Legal Immigration Network, a nonprofit legal aid group.

“You must consider an applicant’s health,” the cable reads. “Certain medical conditions – including, but not limited to, cardiovascular diseases, respiratory diseases, cancers, diabetes, metabolic diseases, neurological diseases, and mental health conditions – can require hundreds of thousands of dollars’ worth of care.”

About 10% of the world’s population has diabetes. Cardiovascular diseases are also common; they are the globe’s leading killer.

The cable also encourages visa officers to consider other conditions, like obesity, which it notes can cause asthma, sleep apnea, and high blood pressure, in their assessment of whether an immigrant could become a public charge and therefore should be denied entry into the U.S.

“All of these can require expensive, long-term care,” the cable reads. Spokespeople for the State Department did not immediately respond to a request for comment on the cable.

Visa officers were also directed to determine if applicants have the means to pay for medical treatment without help from the U.S. government.

“Does the applicant have adequate financial resources to cover the costs of such care over his entire expected lifespan without seeking public cash assistance or long-term institutionalization at government expense?” the cable reads.

The cable’s language appears at odds with the Foreign Affairs Manual, the State Department’s own handbook, which says that visa officers cannot reject an application based on “what if” scenarios, Wheeler said.

The guidance directs visa officers to develop “their own thoughts about what could lead to some sort of medical emergency or sort of medical costs in the future,” he said. “That’s troubling because they’re not medically trained, they have no experience in this area, and they shouldn’t be making projections based on their own personal knowledge or bias.”

The guidance also directs visa officers to consider the health of family members, including children or older parents.

“Do any of the dependents have disabilities, chronic medical conditions, or other special needs and require care such that the applicant cannot maintain employment?” the cable asks.

Immigrants already undergo a medical exam by a physician who’s been approved by a U.S. embassy.

They are screened for communicable diseases, like tuberculosis, and asked to fill out a form that asks them to disclose any history of drug or alcohol use, mental health conditions, or violence. They’re also required to have a number of vaccinations to guard against infectious diseases like measles, polio, and hepatitis B.

But the new guidance goes further, emphasizing that chronic diseases should be considered, said Sophia Genovese, an immigration lawyer at Georgetown University. She also noted that the language of the directive encourages visa officers and the doctors who examine people seeking to immigrate to speculate on the cost of applicants’ medical care and their ability to get employment in the U.S., considering their medical history.

“Taking into consideration one’s diabetic history or heart health history — that’s quite expansive,” Genovese said. “There is a degree of this assessment already, just not quite expansive as opining over, ‘What if someone goes into diabetic shock?’ If this change is going to happen immediately, that’s obviously going to cause a myriad of issues when people are going into their consular interviews.”

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He hasn’t forgotten the pile of hospital bills that awaited him after he had a seizure while tending to customers in his Austin, Texas, barbershop four years ago. Once doctors hurriedly removed the dangerous tumor growing on his brain, a weeklong hospital stay, months of therapy, and nearly $250,000 worth of medical expenses followed.

The coverage he has purchased for years through the Affordable Care Act marketplace covered most of those bills.

“That saved my ass,” said Cleveland, who owns three barbershops across the city.

Even with Cleveland’s monthly premiums expected to soar next year — from $560 to about $682 — he will still sign up for a plan that requires him to shell out $70 if he sees a doctor and 50% of the cost for any emergency room visits. Still, Cleveland is most worried about some of his employees, who might risk going without insurance once they see the high prices.

Small-business owners are among those who stand to lose the most should Congress let the additional, generous federal subsidies put in place during the covid-19 pandemic lapse. The looming change threatens not only their own coverage but also that of their employees, who often depend on marketplace coverage.

Whether to extend the enhanced ACA subsidies that cost taxpayers billions of dollars yearly poses a serious political conundrum for Republicans. After years of unified opposition to Obamacare, the party now faces pressure from one of its most loyal constituencies, small-business owners, who will bear the brunt of rising premiums if the subsidies disappear.

Most of the roughly 20 employees who work on Justin Miller’s 113-year-old family fruit farm in rural Northern California purchase coverage through the Obamacare marketplace.

He’s agonizing over what it could mean if health insurance through the marketplace becomes unaffordable for his employees. He fears they might consider leaving his farm for a job that comes with health coverage.

“Being a small-business owner, especially in a field like ours, where it is tough work and we really understand how hard everybody works, we have to look everybody in the eyes every day,” Miller said. “Knowing that they’re going to have to pay $4,000 or $5,000 more a year to stay on their insurance is a tough pill to swallow.”

Miller says he already pays a minimum wage of $22.50 and provides sick leave, vacation, retirement, and employee housing benefits.

Adding health insurance for his employees, he said, would be too costly to keep his farm in business.

GOP Pollsters Issue ACA Caution

About half of the 24 million people enrolled in Obamacare coverage are, or are employed by, small-business owners — a group that is more likely to vote Republican and overwhelmingly backed President Donald Trump in last year’s election. Farmers, dentists, real estate agents, and chiropractors are among the professions most represented among enrollees.

Even Trump’s own pollsters have found deep support for the Obamacare subsidies, warning that failing to extend them could cost Republicans in next year’s midterms.

A poll conducted last month by Republican pollster John McLaughlin found that a majority of independent voters would be less likely to vote for politicians who voted to let the enhanced tax credits expire.

Given that “approximately 4 million” people would lose coverage and premiums would “skyrocket by an average of 75%,” the poll also concluded that: “A candidate for congress who let the healthcare tax cuts expire would also be vulnerable to more pointed messages.”

Red States Benefited From the Subsidies

Some red states have seen Obamacare enrollment balloon since the federal government began offering extra help paying premiums in the form of more generous subsidies.

Texas and Florida have added 2.8 million enrollees each since 2020, far outpacing growth in most other states. Together, the two states now account for more than a third of marketplace enrollment nationally.

A small chorus of Republican lawmakers — up for reelection next year, mostly in competitive races — have proposed an extension of the subsidies, urging Democrats to vote to reopen the government while simultaneously pleading with House Speaker Mike Johnson to work out a bipartisan deal that doesn’t allow them to simply lapse.

At Cleveland’s barbershops in Austin, about a third of his 18 employees rely on Obamacare coverage. He’s talked to them about their health insurance options for next year but said many hadn’t started thinking about open enrollment, which began Nov. 1.

He’s worried they’ll be baffled once they see the new prices, which currently reflect what customers will pay next year without an extension of the extra subsidies.

“There’s a couple of my barbers that are going to go without, because they’re healthy and young, but I thought I was too when everything happened to me,” said Cleveland, now 47.

Republicans, meanwhile, remain wary of voting to extend the additional Obamacare subsidies, said Rodney Whitlock, a vice president at the McDermott+ consultancy who was a longtime congressional staffer and advises on health care policy.

No Republican voted for the extra subsidies when they were introduced in 2021 or continued in 2022. Approving them now, he said, is viewed by many as a band-aid that would temporarily help a program GOP leaders have long lambasted as problematic and too costly.

But, Whitlock noted, many in the party are coming to terms with how the subsidies might affect their changing constituencies. Nearly 6 in 10 Obamacare enrollees live in a Republican-held congressional district.

“Republicans are slowly starting to grasp that the lower third of income earners are their voters,” he said. “For the first time, I think they’re getting there. That battleship turns slowly.”

Rep. Marjorie Taylor Greene, a Georgia Republican who has firmly backed Trump, broke with her party last month, calling on the GOP to extend the subsidies. Greene said in an interview that rising health care costs are the “No. 1 issue” she hears about from people living in her district.

“I know a lot of small-business owners, like a family of four, and they’re paying $2,000 a month,” Greene said during the television interview, adding that rising deductibles make the insurance hardly functional for anything other than catastrophes.

She warned in another TV interview that “ignoring” the issue could be “very bad for midterms” next year.

Miller, the farmer who lives in a conservative district in Northern California, expects monthly health insurance premiums for himself, his wife, and two of his children to jump from $264 to $600. His deductibles and copayments are going up, too. He expects all these new expenses will still be on his mind when he goes to vote in the midterm elections next year, he said. Describing himself as an independent, Miller said he is frustrated that few American politicians talk about the type of universal health care coverage that’s available in other countries.

“I’m definitely voting for those that will protect the working American, regardless of party,” he said.

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Higher prices and uncertainty await many of those shoppers. 

Average premiums are expected to more than double. The directors who manage marketplace enrollment in states including Maryland, California, Pennsylvania, and Idaho told me and my colleague Julie Appleby that people are wondering how they’ll scrape together hundreds — or even thousands — of dollars more next year to pay for these plans. Some people are considering plans with five-figure deductibles, like one Virginia Beach, Virginia, family facing a $20,000 deductible to keep their monthly premiums near $70. 

“They might look cheap premium-wise, but the coverage itself is going to end up costing that family a lot,” Deepak Madala, the director of Enroll Virginia, told me this month. 

Even as Americans weigh high-priced plans, there’s the very real possibility that everything could change if Congress strikes a last-minute deal to extend the subsidies before the end of open enrollment, which runs through Jan. 15 in most states. 

Behind the scenes, the directors of state-based exchanges are drawing up contingency plans. 

In Idaho, the state exchange director says he has “notices ready to go” should Congress work something out. California and Maryland are preparing to temporarily close open enrollment if lawmakers agree to extend the subsidies. 

On Capitol Hill, insurers are warning lawmakers that time is running out. 

“If things go past the first week of December, it does get much more operationally complicated,” Kris Haltmeyer, the vice president for legislative and regulatory policy at the Blue Cross Blue Shield Association, told me. 

Still, a month into the government shutdown, Congress appears no closer to a deal to extend the extra subsidies that have made marketplace health insurance more affordable since 2021, when Democrats first approved a law that provided significant assistance to pay premiums. 

Republican and Democratic leaders have expressed a desire to find a solution before those subsidies lapse at year’s end. 

But, as is typical with Congress, each party has different ideas about what a deal might look like. And lawmakers haven’t agreed even on how to take a first step. Democrats have demanded an agreement on the ACA subsidies before they will vote to fund the federal government. Republicans, meanwhile, have balked, saying they’ll negotiate only after the government is reopened. 

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As shopping season opens for Affordable Care Act plans in some states, customers are confronting staggering costs for their health insurance next year. The extra federal subsidies put in place in 2021 that made coverage more affordable for millions of people will expire at the end of this year unless a gridlocked and idle Congress acts.

With Democratic and Republican lawmakers at an impasse, the federal government shut down on Oct. 1, spurred by the need for an estimated $353 billion over a decade to continue providing enhanced ACA subsidies for roughly 24 million people. Both sides have dug in, with Republicans saying Senate Democrats must vote to reopen the government before they’re willing to negotiate on the ACA’s costs.

If Congress does manage to strike a deal in the coming days or weeks to extend some subsidies, the prices and types of plans available on the online marketplaces could change dramatically, bringing unprecedented uncertainty and upheaval to this year’s open enrollment, which begins in most states on Nov. 1.

Michele Eberle, executive director of the Maryland Health Benefit Exchange, the state-run marketplace, is gaming out strategies should that happen, including the possibility of pausing enrollment so her 200-person team can update the plans to reflect any changes, should Congress pass a new bill on ACA subsidies.

“We will do whatever it takes to make sure we can provide Marylanders with the most affordable health coverage,” Eberle said. “The mechanics of how that gets done, we don’t really know until we figure out what Congress might do.”

“I think everyone realizes that, depending on what happens, we just can’t flip a switch overnight,” she added.

Exchange customers in Maryland can expect to pay, on average, about 35% more next year, even with help from the state, which agreed to offer backup subsidies should the federal government’s discounts expire at the end of this year. Eberle said notices of premium hikes — which assumed the federal subsidies would expire — already were sent to mailboxes and inboxes. One middle-income family of four in the state, for example, will see their monthly premiums go from $916 to $1,427.

People living in most states still use healthcare.gov, the federal marketplace, to enroll in coverage. The Centers for Medicare & Medicaid Services, which oversees the federal exchange, declined to answer questions about how quickly the agency could pivot on any changes Congress may make after sign-ups start.

“CMS does not speculate on potential Congressional action,” Health and Human Services spokesperson Emily Hilliard said in an email.

Like other states that run their own ACA exchanges, California has sent letters to policyholders with information about their 2026 coverage, with costs calculated under the assumption that the subsidies would expire.

But the California exchange team, too, devised backup plans to contact policyholders and revamp its online marketplace if Congress acts before year’s end.

“At no point is it too late,” said Jessica Altman, executive director of Covered California, the state’s exchange. “We are ready to move any mountain we can possibly move to make any changes as quickly as we possibly can.”

It could take about a week to reprogram the site to reflect prices that factor in more generous subsidies, if Congress were to approve them exactly as they currently are, Altman said.

States may also have to update premiums themselves to reflect new rates. Most insurers submitted two sets of premium rates to states this year in case Congress agreed to extend the subsidies.

Right now, many shoppers are seeing the set of higher rates that insurers plan to charge if the subsidies expire.

Insurers say it is necessary to raise premiums without the subsidies because they anticipate healthier, younger people will drop coverage rather than pay more. That would leave insurers with a sicker, older pool of people to cover.

If a subsidy deal is reached, insurers could lower the premiums.

The complications don’t end there.

If Congress passes a subsidy deal after customers have started picking plans, people might see the new prices and want to reconsider the type of coverage for which they already signed up. Enrollees may change plans as long as enrollment is open, through Jan. 15 in most states.

Dozens of insurers offer ACA plans across the country. Those plans range widely in the doctors or medications they cover, as well as how much customers contribute in copays, the fees owed for medical services, and deductibles, the out-of-pocket amount paid before insurers pitch in.

Some people might be willing to pay a higher monthly premium in exchange for a lower deductible. Others, especially those who don’t expect to incur major medical bills, might risk a higher deductible to keep monthly premium payments lower.

In Virginia, some customers are being presented with strikingly high deductibles for next year, said Deepak Madala, the director of Enroll Virginia, which assists people with enrolling in coverage.

He said he’s helping one family in Virginia Beach facing a jump in premium costs from $70 to about $280 a month.

To buy a plan at a similar price, the family, with a household income of about $60,000, would need to look at coverage that carries a deductible of $20,000 or more, he said. Right now, their deductible is $800.

With premiums and deductibles that high, some customers might rethink coverage entirely, he said.

They’re deciding whether “to go without or switch to a plan with a very high deductible,” Madala said of ACA customers’ options.

Pennsylvania’s state-based exchange, which last week started sending out notices detailing 2026 rates, estimates a 102% increase in premiums for its roughly 500,000 customers. About a third of customers are expected to drop coverage, said Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority.

The timing of any subsidy deal reached by Congress is most precarious, though, for the roughly 135,000 Idahoans enrolled in ACA coverage.

That’s because their state opened enrollment on Oct. 15, weeks before the rest of the country — and it will end earlier, on Dec. 15.

With ACA enrollees facing average increases of 75% for coverage costs, about 20% are expected to drop out of the marketplace, said Pat Kelly, executive director of Your Health Idaho, the state exchange.

Idaho is prepared to revamp its website if anything changes on the subsidies — a process that could take days — and has “notices ready to go” to inform policyholders of additional savings, Kelly said.

“We would work to do it as quickly as possible, and make sure it is done right,” he said, adding that factors such as the day of the week or proximity to the Thanksgiving holiday could add time.

If Congress waited to act until the federal subsidies expire on Dec. 31 — the date Republican House Speaker Mike Johnson has repeatedly raised as the deadline for a deal — it would be too late for people in Idaho.

“We would run out of open enrollment, and there would not be enough time to make changes,” Kelly said of any congressional deals reached after mid-December.

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Those votes, he cautioned, are at risk if Congress doesn’t pass a law to preserve lower premiums on Affordable Care Act marketplace plans for the roughly 4.7 million people living in his home state of Florida who are enrolled in the coverage.

“Hispanic voters helped return Donald Trump to the White House,” said Fuentes, CEO of the Florida State Hispanic Chamber of Commerce, who called on Congress to reopen the government to work out a deal on the tax credits. “Republican leaders would do right by their constituents to keep coverage affordable, and they will remember that heading into the midterms.”

With less than a month to go before many Americans pick their health insurance plans for the next year, Democrats in Congress are holding up government funding to pressure Republicans into extending billions of dollars in federal tax credits that have in recent years dramatically lowered premiums and contributed to record-low rates of uninsured Americans.

Democrats see the high-stakes standoff as a chance to talk about affordable health care as millions of Americans — including those enrolled in coverage through a workplace or Medicare — brace for higher costs next year. Party leaders, hoping to win back support from some of the working-class supporters who have drifted away from them, have used the moment to remind voters of the recent cuts Republicans have approved to some health care programs.

Republicans are outwardly exuding confidence that the approach will not find traction, reminding the public that Democrats forced the shutdown. But a new KFF analysis shows that 80% of all premium tax credits benefited enrollees in states Trump won.

The shutdown coincides with open enrollment season, with insurers preparing to send notices revealing next year’s premium rates for roughly 24 million people enrolled in ACA coverage. The average enrollee is expected to pay more than double if the tax credits are left to expire. Insurers have also said they’ll have to dramatically raise the price of premiums because healthier people will opt out of coverage as it becomes more expensive, leaving a sicker pool of Americans — and less money to cover them.

“Over the next few days, what you’re going to see is more than 20 million Americans experience dramatically increased health care premiums, copays, and deductibles because of the Republican unwillingness to extend the Affordable Care Act tax credits,” House Minority Leader Hakeem Jeffries said Oct. 2 on the steps of the Capitol.

Open enrollment in most states begins on Nov. 1. Some insurers and exchanges have delayed sending notices detailing premium rates for next year, because they are waiting to see what unfolds in Washington. For example, Covered California, the state’s insurance marketplace, is planning to mail out notices to more than a million enrollees later than usual this year, on Oct. 15.

From her home in Richmond, Virginia, 31-year-old Natalie Tyer is anxiously awaiting the arrival of her notice. She checks the state’s marketplace website daily to see whether new rates for her insurance plan have been posted.

Tyer has been relying on marketplace coverage for over a year now while she works part-time for a small video production company and pursues a master’s degree to become a school counselor. The tax credits help cover $255 of her monthly premium, bringing it down to $53. Since she’s generally healthy, if the credits expire and her premiums go up significantly, she might drop coverage altogether.

“I very well might have to go without health insurance and may have to rely on hope,” Tyer said.

Democrats’ push to center the shutdown on health care affordability, though, runs up against many uncomfortable realities of the federal government’s closure, which will leave millions of federal workers without paychecks, hamper some functions of public health agencies, and threaten food assistance payments for low-income mothers, among other effects.

The ACA, meanwhile, has been a political flash point since 2010, when Republicans fought against the passage of the landmark health care legislation. A wave of Republican congressional victories soon followed that fight, spurring a government shutdown in 2013, when the GOP tried to gut the program. Party leaders again tried to repeal it in 2017 to follow through on a Trump campaign promise.

The latest clash — over the billions of dollars in tax credits that Democrats issued during the covid-19 pandemic to boost enrollment in the ACA — has been simmering for months. Democrats, who wrote the original legislation introducing and then extending them, set the enhanced tax credits to expire at the end of this year. Even some Republicans began warning this summer that letting those tax credits lapse could be detrimental, with Republican pollsters Tony Fabrizio and Bob Ward issuing a memo cautioning that an extension of the credits could make a difference in next year’s midterm election.

Extending the ACA tax credits, which have reduced monthly premiums to as little as $0 for poorer enrollees and capped the amount middle-income Americans pay to just 8.5% of their income, also would be a popular move.

More than three-quarters of Americans want those tax credits to continue, according to a new KFF poll conducted before the shutdown. About 3 in 4 people said they will blame Trump or the GOP if they end. KFF is a health information nonprofit that includes KFF Health News.

Although they’ve declined to address the tax credits so far this year, Republican Party leaders have signaled they are willing to extend the ACA tax credits, but with new restrictions on who qualifies for them. GOP leadership has also said they want to hash out the policy details over several weeks, not under the gun of a shutdown.

On Oct. 6, House Speaker Mike Johnson accused Democrats of manufacturing a political issue to shut down the government and urged them to pass the continuing resolution just to “keep the lights on.”

“They decided that they would pick a fight on health care,” Johnson said, adding that he believes the tax credits are “a Dec. 31 issue,” referring to when the credits are set to expire.

Since open enrollment begins next month, insurers will need to start posting premium prices for customers to window-shop in the coming days. Democrats have argued that waiting months to work out a deal, which could change those prices, might spur widespread confusion.

While more Americans appear to be faulting Trump and Republicans for the shutdown, only a quarter of people are convinced that the Democrats’ proposal to extend the ACA tax credits is worth closing the government over, according to a CBS News poll over the weekend.

Health care is typically a winning message for Democrats, who have struggled to coalesce around issues that appeal to the working class in recent years, said William Pierce, a health policy consultant who served under President George W. Bush.

“It’s all about health care. They need to make this all about health care,” Pierce said, describing it as a weak spot for Republicans. “They need to just keep talking about it, constantly.”

Republicans in the White House and Congress have countered with factually dubious claims that Democrats are seeking to expand free health care for immigrants who do not have legal status in the U.S.

In fact, such immigrants are not eligible for enrollment in the marketplace, and Democrats have not proposed opening ACA coverage to them in their proposal.

Back in Richmond, as Tyer worries about her coverage for next year, she’s bothered to see the debate focus on immigrants. Some of her classmates and colleagues are worried, too.

“The reality is, what’s happening with these tax credits is that normal people — people who want to work in the public sector, who want to educate kids — we are also going to lose health care,” Tyer said.

KFF Health News senior correspondent Bernard J. Wolfson contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Esos votos, advirtió, están en riesgo si el Congreso no aprueba una ley que mantenga bajos los costos mensuales de los planes del mercado establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA) para aproximadamente 4,7 millones de personas que tienen esa cobertura en Florida, su estado natal.

“Los votantes hispanos ayudaron a que Donald Trump regresara a la Casa Blanca”, dijo Fuentes, presidente de la Cámara de Comercio Hispana del Estado de Florida. “Los líderes republicanos harían bien en mantener la cobertura médica accesible, y sus votantes lo recordarán al acercarse las elecciones legislativas”.

A menos de un mes para que muchas personas elijan su plan médico para el próximo año, los demócratas en el Congreso han bloqueado la aprobación de fondos para el gobierno, para presionar a los republicanos. El objetivo es que extiendan miles de millones de dólares en subsidios federales que, en los últimos años, han reducido dramáticamente los costos mensuales y contribuido a una cifra récord de personas con seguro médico.

Los demócratas ven este momento político como una oportunidad para hablar sobre la necesidad de que la atención médica sea accesible, justo cuando millones de personas —incluidas quienes tienen cobertura a través del trabajo o de Medicare— se preparan para enfrentar costos más altos el próximo año.

Con la esperanza de recuperar el respaldo de algunos votantes de clase trabajadora que se han alejado de ellos, los líderes del partido han aprovechado para recordar los recortes a programas de salud que los republicanos han aprobado recientemente.

Por su parte, los republicanos se muestran muy seguros en público de que esta estrategia no tendrá impacto, y le recuerdan a la gente que fueron los demócratas quienes provocaron el cierre del gobierno. Sin embargo, un nuevo análisis de KFF muestra que el 80% de todos los subsidios para pagar las primas beneficiaron a personas inscritas en estados donde ganó Trump.

El cierre coincide con el inicio de la temporada de inscripción abierta, cuando las aseguradoras se preparan para enviar avisos con las tarifas del próximo año a unas 24 millones de personas inscritas en planes de ACA.

Si los subsidios expiran, se espera que el costo mensual para el beneficiario promedio se duplique. Las aseguradoras también han advertido que se verán obligadas a subir considerablemente los precios de las primas, ya que muchas personas sanas podrían dejar de pagar por cobertura si se vuelve demasiado costosa, dejando un grupo de asegurados más enfermos y con menos recursos para cubrirlos.

“En los próximos días, más de 20 millones de estadounidenses verán aumentos drásticos en sus primas, copagos y deducibles debido a que los republicanos se niegan a extender los subsidios de la Ley de Cuidado de Salud a Bajo Precio”, dijo Hakeem Jeffries, líder de la minoría demócrata en la Cámara de Representantes, el jueves 2 de octubre en las escalinatas del Capitolio.

En la mayoría de los estados, la inscripción abierta comienza el 1 de noviembre. Algunas aseguradoras y mercados estatales han retrasado el envío de avisos con las tarifas del próximo año porque están esperando a ver qué sucede en Washington. Por ejemplo, Covered California, el mercado de seguros del estado, planea enviar los avisos a más de un millón de personas inscritas más tarde de lo habitual este año, para el 15 de octubre.

Desde su casa en Richmond, Virginia, Natalie Tyer, de 31 años, espera con ansiedad la llegada de su aviso. Revisa a diario el sitio web del mercado estatal para ver si ya publicaron las nuevas tarifas de su plan.

Tyer ha dependido de la cobertura del mercado por más de un año, mientras trabaja medio tiempo en una pequeña empresa local de producción de video y cursa una maestría para convertirse en consejera escolar. Los subsidios cubren $255 de su prima mensual, lo que reduce su pago a $53. Como en general tiene buena salud, si los créditos expiraran y su prima aumentara significativamente, es probable que tuviera que abandonar la cobertura.

“Es probable que tuviera que quedarme sin seguro médico y depender de la esperanza”, dijo Tyer.

Sin embargo, el esfuerzo de los demócratas por centrar el debate del cierre del gobierno en el tema de los costos de salud choca con muchas otras realidades incómodas del cierre: millones de empleados federales sin cobrar sus salarios, interrupción de algunas funciones de agencias de salud pública y el riesgo de que se suspendan pagos de asistencia alimentaria para madres de bajos ingresos, entre otras consecuencias.

ACA ha sido un punto de tensión política desde 2010, cuando los republicanos se opusieron a la aprobación de esta histórica ley de salud. Poco después, el partido ganó numerosas elecciones legislativas, lo que llevó a otro cierre del gobierno en 2013, cuando intentaron eliminar el programa. En 2017, los líderes republicanos intentaron de nuevo derogar la ley, como parte de una promesa de campaña de Trump.

El conflicto actual —en torno a los miles de millones de dólares en subsidios que los demócratas impulsaron durante la pandemia de covid para aumentar la inscripción en ACA— ha estado latente durante meses.

Los mismos demócratas que redactaron la legislación que introdujo y luego amplió estos beneficios, programaron que los subsidios mejorados expiraran a finales de este año. Incluso algunos republicanos advirtieron este verano que permitir que expiren podría ser perjudicial. Los encuestadores republicanos Tony Fabrizio y Bob Ward publicaron un memorando donde advirtieron que extender los créditos podría marcar la diferencia en las elecciones legislativas del próximo año.

Extender los subsidios de ACA, que han reducido las primas mensuales a tan solo $0 o $10 para las personas de bajos ingresos y han limitado el gasto de las personas de ingresos medios a solo el 8,5% de sus salarios, también es una medida popular entre muchos estadounidenses.

Más de tres cuartas partes de los estadounidenses quieren que esos subsidios continúen, según una nueva encuesta de KFF realizada antes del cierre. Aproximadamente 3 de cada 4 personas afirmaron que culparán a Trump o al Partido Republicano si se cancelan.

Aunque en lo que va del año se han negado a abordar el tema, los líderes del Partido Republicano han indicado que están dispuestos a extenderlos, pero con nuevas restricciones sobre quiénes califican para obtenerlos. También han dicho que quieren debatir los detalles de la política durante varias semanas, no bajo la presión de un cierre.

El 6 de octubre, el presidente de la Cámara de Representantes, Mike Johnson, acusó a los demócratas de inventar un problema político para cerrar el gobierno y los instó a aprobar la resolución de continuidad solo para “mantener la atención médica”.

“Decidieron que iniciarían una disputa sobre la atención médica”, dijo Johnson, y agregó que cree que los subsidios son “un asunto del 31 de diciembre”, refiriéndose a la fecha de vencimiento prevista.

Dado que la inscripción abierta comienza el próximo mes, las aseguradoras deberán comenzar a publicar los precios de las primas para que los clientes puedan comparar precios en los próximos días. Los demócratas han argumentado que esperar meses para llegar a un acuerdo, que podría cambiar esos precios, podría generar una confusión generalizada.

Si bien cada vez más estadounidenses parecen culpar a Trump y a los republicanos por el cierre del gobierno, solo una cuarta parte de la población está convencida de que la propuesta demócrata de extender los subsidios de ACA justifique el cierre del gobierno, según una encuesta de CBS News realizada el fin de semana del 4 de octubre.

La atención médica suele ser un mensaje ganador para los demócratas, quienes han tenido dificultades para unirse en torno a temas que atraen a la clase trabajadora en los últimos años, afirmó William Pierce, consultor de políticas de salud que trabajó durante la presidencia de George W. Bush.

“Todo gira en torno a la atención médica. Necesitan que todo esto gire en torno a la atención médica”, dijo Pierce, describiéndolo como un punto débil para los republicanos. “Necesitan seguir hablando de ello constantemente”.

Los republicanos en la Casa Blanca y el Congreso han contraatacado con afirmaciones, basadas en hechos dudosos, de que los demócratas buscan ampliar la atención médica gratuita para los inmigrantes sin estatus legal en el país.

De hecho, estos inmigrantes no pueden inscribirse en el mercado de seguros médicos, y los demócratas no han planteado abrirles la cobertura de ACA en su propuesta.

De vuelta en Richmond, mientras Tyer se preocupa por su cobertura para el próximo año, le preocupa también ver que el debate se centre en los inmigrantes. Algunos de sus compañeros de clase y colegas también están preocupados.

“La realidad es que lo que está sucediendo con estos subsidios es que la gente común —quienes quieren trabajar en el sector público, quienes quieren educar a sus hijos— también vamos a perder la atención médica”, dijo Tyer.

El corresponsal senior de KFF Health News, Bernard J. Wolfson, contribuyó con este informe.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

Federal funding ran out at midnight on Oct. 1, after Congress failed to pass even a stopgap budget while negotiations continued.

Now the question is how long the deadlock will last, with Democrats pitted against Republicans and a presidential administration that has broken with constitutional norms and regularly used political intimidation and primary threats to achieve its ends. Because Republicans hold only a slim majority in the Senate, any deal will need to attract at least a few Democratic votes.

Ramifications from a shutdown on public health systems and health programs will be felt far beyond Washington, D.C., halting almost all of the federal government’s nonessential functions, including many operations related to public health.

Even on Sept. 30, as the clock ticked toward midnight, President Donald Trump renewed threats about mass firings of federal workers if Democrats didn’t acquiesce to GOP demands. Some people worry that such workforce reductions would further enable the administration to undermine federal government operations and reduce the budget impasse to what’s been described as three-dimensional chess or a game of chicken.

Such threats to fire, rather than temporarily suspend, federal workers are “unprecedented,” said G. William Hoagland of the Bipartisan Policy Center. The lack of negotiations between Capitol Hill Republicans and Democrats in advance of the shutdown is also unprecedented in his experience, said Hoagland, a longtime GOP Senate Budget Committee aide.

The stalemate centers largely on health coverage, with Democrats and Republicans clashing over the Affordable Care Act and Medicaid cuts. For Americans with ACA marketplace plans, government subsidies cap the percentage of household income they must pay toward premiums. Lawmakers expanded the subsidies in 2021 and extended that additional help through the end of 2025, and the looming expiration of those expanded subsidies would increase costs and reduce eligibility for assistance for millions of enrollees.

Democrats want a further extension of the subsidies, but many GOP lawmakers are resistant to extending them as is and say that debate must wait until after a budget deal to keep the federal government afloat. Antagonism has grown, with the parties in a pitched battle to convince voters the other party is to blame for the government’s closure.

Said Senate Minority Leader Chuck Schumer on the Senate floor Sept. 30: “Republicans have chosen the losing side of the health care debate, because they’re trying to take away people’s health care; they’re going to let people’s premiums rise.”

But Senate Majority Leader John Thune accused Democrats of attempting to “take government funding hostage.”

The longer a shutdown lasts, the more impacts could be felt. For example, some community health centers would be at risk of closure as their federal funding dries up.

Long-term projects by the Federal Emergency Management Agency to reduce damage from future natural disasters will stop, for example. Rescue services at national parks that stay open will be limited. And at the National Institutes of Health, many new patients awaiting access to experimental treatments may not be admitted to its clinical center.

Entitlement programs such as Medicaid and Medicare will continue, as will operations at the Indian Health Service. But disease surveillance, support from the Centers for Disease Control and Prevention to local and state health departments, and funding for health programs will all be hampered, based on federal health agencies’ contingency plans.

The Department of Health and Human Services is expected to furlough about 40% of its workforce, which has already been downsized by about 20,000 positions under the Trump administration. Across the federal government, roughly 750,000 employees will be furloughed, according to an estimate released Sept. 30 by the Congressional Budget Office, a nonpartisan agency that calculates the cost of legislation. While furloughed employees won’t be working, eventually they will get back pay, totaling about $400 million daily, the CBO estimated.

At HHS, research is expected to pause on the links between drug prices and the Inflation Reduction Act, the major law enacted under former President Joe Biden to boost the economy. Despite reports that Food and Drug Administration Commissioner Marty Makary said the FDA would basically be untouched, the agency won’t accept new drug applications and food safety efforts will be reduced. Federal oversight of a program that helps hospitals save lives and evacuate individuals in environmental crises is expected to stop.

Fewer federal staff will be available to provide help to Medicaid and Medicare enrollees. CDC responses to inquiries about public health matters will be suspended. And the work of a federal vaccine injury program is also anticipated to stop.

Congressional Democrats insist the ACA subsidies must be renewed now because enrollment for the Obama-era health program opens on Nov. 1. Without the extended subsidies, health insurers are warning of double-digit premium hikes for millions of enrollees.

House Democratic Leader Hakeem Jeffries has argued that a “Republican-caused health care crisis” is hanging over Americans as a result of Trump’s new tax-and-spending bill, which adds restrictions to Medicaid that are expected to kick millions off the program. Republicans have also advanced mass layoffs and funding cuts at the nation’s health department and caused widespread confusion over access to some vaccines.

“We’re not going to simply go along to get along with a Republican bill that continues to gut the health care of everyday Americans,” Jeffries told reporters Sept. 29. “These people have been trying to repeal and displace people off the Affordable Care Act since 2010.”

Republicans, meanwhile, have blasted Democrats for holding up funding over the subsidies and say any deal will require concessions.

“If there were some extension of the existing policy, I think it would have to come with some reforms,” Thune, the Senate Republican leader, said Sept. 26.

Such a deal may involve changes to a policy that caps what consumers have to pay for ACA marketplace plans at 8.5% of their income, no matter how much they earn. It could also alter their ability to obtain plans with no premiums, an option that became more widely available because of the beefed-up subsidies.

Adding restrictions to the ACA subsidies is likely to decrease enrollment in the program, which saw declines during the first Trump administration and did not reach 20 million for the first time until last year, a milestone reached in large part due to the subsidies.

Several Republicans have expressed interest in extending the subsidies, including a group of GOP representatives who proposed legislation to do so last month.

Democrats may be betting that the timing of the shutdown will put pressure on their Republican colleagues to come to the negotiation table on the ACA subsidies.

Within days of the government’s closure, ACA enrollees are expected to get notices from their health insurers advising them of steeper premiums. Insurers have said the expiring subsidies have forced those large premium hikes because the healthiest and youngest people are more likely to opt out of coverage when prices go up.

The White House, meanwhile, ramped up its pressure campaign on Democrats. White House press secretary Karoline Leavitt insisted Sept. 29 that Trump wants to keep the government open.

“Our most vulnerable in our society and our country will be impacted by a government shutdown,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).