Chloe Chalakani has a lot at stake in the health care fight at the heart of the government shutdown.
Chalakani runs a small culinary business with her partner in the coastal town of Thomaston, Maine. As temperatures drop and the height of her busy tourist season winds down, she's hitting her list of fall administrative tasks, including health insurance enrollment. She uses CoverME.gov, the Affordable Care Act marketplace in Maine, also known as Obamacare.
Her options for 2026 are looking grim.
"My premium is already $460 a month, and that is for the highest deductible plan that exists," she says. She's 31 years old and fairly healthy. Extra financial help with premiums — in the form of enhanced tax credits — expires in December, and rates are going up.
"I don't plan to get insurance next year," she says. "I'm just not going to do it — I'll pay out of pocket."
The prospect of young people dropping out of the ACA markets worries health policy experts — not just because of their own personal risk of going uninsured, but because of the effect that millions of people making the same decision could have on the whole health system.
How insurance works
Health insurance markets only function when there are lots of people pooling their resources — young and old, relatively healthy and not.
"You need people to be paying into the insurance system when they're healthy so that they can take out when they're sick," explains Cynthia Cox of KFF, a nonpartisan health research organization.
Younger, healthier people tend to pay more into the system than they consume in health care. Older, sicker people often consume an amount of health care that costs more than the amount they pay in. That dynamic creates a stable insurance system.
Right now, the Affordable Care Act markets seem to be pretty balanced. A record 24 million people are enrolled, and brokers report their clients are generally happy with their plan options and find the premiums affordable.
That may be about to change. Premium costs will soon explode for many consumers because of the expiration of certain federal subsidies that kept those monthly costs low. It's the issue at the heart of the current federal shutdown — Democrats want the subsidies to be extended, Republicans say those negotiations shouldn't be part of the government funding debate.
The dreaded 'death spiral'
If Congress does not extend the federal subsidies set to expire in December, the Congressional Budget Office estimates that 4 million people will become uninsured in the next several years.
The people who opt to go without insurance will probably be younger and healthier, Cox says, "because sicker, older people will be more motivated to keep their coverage, even if that means paying a lot more each month."
It's easy to find people who fit these profiles. Chalakani, the 31-year-old in Maine plans to skip coverage, while a 64-year-old in West Virginia who needs expensive medications tells NPR she's saving up money now to pay $2,800 every month for her coverage next year.
"If you only have sick people buying health insurance plans, then the average cost of that plan is going to be very high," Cox says. "The concern is that the least sick person in that group is going to drop their coverage because it becomes unaffordable, and then the next year, the least sick person in that group might drop their coverage because it becomes unaffordable and on and on."
This is what's called a death spiral for an insurance market, she explains. "Premiums get so high that only the sickest of the sickest people are enrolled, and eventually insurance companies just are not going to want to participate in a market like that — it's just not going to function."
Although it is a relatively small portion of Americans who buy these plans, it has the potential to hurt everyone, regardless of how they're insured. If more people in the country become uninsured, that's hard on hospitals and health care access.
"If hospitals face a lot of financial strain from having a lot more uninsured patients coming through their doors, then they might start changing the services they offer," she says. "They may have to close the maternity ward. They might have to close down altogether."
That's already starting to happen in Maine and other parts of the country, where health care markets are under financial pressure. And that pressure is increasing with looming cuts to Medicaid from President Trump's budget law that are expected to increase the number of uninsured people by millions more.
Open enrollment is Nov. 1
Weeks into the shutdown, federal lawmakers have apparently not started negotiations to overcome the stalemate. The two sides have been at an impasse since Oct. 1.
Meanwhile, open enrollment is coming on Nov. 1 — in Idaho, it's already begun. Unless Congress acts quickly, enrollees will likely have sticker shock when they log in to find a plan for 2026. On average, consumers will have to pay double next year for the same plan.
Chloe Chalakani says she plans to go uninsured even though she knows that car accidents and serious illnesses can happen. "Should a catastrophe happen, I'll probably say, 'Wow, I should have had insurance,'" she says. "But at this point, I don't have the financial ability to plan for that."
If lawmakers do overcome the impasse and extend the enhanced subsidies so her premiums stay about the same, she says she might reconsider her plan to go without health insurance in 2026.
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