With open enrollment set to begin on November 1, healthcare providers across North Carolina are facing more than the usual seasonal rush. The ongoing federal government shutdown and the unresolved fight in Congress over Affordable Care Act (ACA) subsidies are creating uncertainty for patients and the people who care for them.
At issue are the enhanced ACA premium subsidies that have helped make health insurance affordable for hundreds of thousands of North Carolinians since 2021. Unless Congress acts, those subsidies will expire at the end of the year. For many, that could mean significantly higher premiums or no coverage at all.
What’s Going on in Washington
The government is shut down because lawmakers haven’t agreed on a long-term budget. While key healthcare services are still running, the Centers for Medicare & Medicaid Services (CMS) has had to furlough staff, although some have been recalled to keep HealthCare.gov and state marketplaces operational.
The bigger policy fight centers on the future of the ACA’s expanded premium tax credits. These subsidies, first boosted under the American Rescue Plan and later extended through the Inflation Reduction Act, are now set to run out in December 2025.
- Democrats say the subsidies are essential to keeping coverage affordable.
- Republicans want a straightforward funding bill, with no extra spending or long-term subsidy commitments.
If the gridlock continues, the ripple effects could hit insurance companies, enrollment support staff, and healthcare providers across the country — especially in high-enrollment states like North Carolina.
What It Means for North Carolina
North Carolina’s ACA marketplace has grown quickly in recent years. Over 1 million people signed up for coverage in 2024, and most of them receive some form of financial help. Without those subsidies, many would be priced out.
To put that in perspective:
- A single adult earning around $28,000 a year could see their monthly premium jump from $25 to more than $150.
- Middle-income families — who only recently became eligible for subsidies — could lose all financial support.
- Patients may start skipping doctor visits, stretching medications, or dropping insurance altogether. That means more uncompensated care for clinics and hospitals already operating on tight margins.
For safety net providers and community health centers, the stakes are especially high. With Medicaid expansion continuing in North Carolina, the ACA marketplace serves as a crucial option for people who fall just above the Medicaid eligibility line. Disruptions here could undo years of progress.
What Providers Can Do Right Now
Healthcare providers can’t solve the policy fight in Washington, but there are practical steps they can take to support their patients and prepare for what’s ahead.
1. Talk to Patients Early
Start conversations now — especially with patients who rely on ACA marketplace coverage.
Even though final subsidy details are still uncertain, patients need to understand how income, household size, and employment changes could affect their eligibility and premium costs.
Encourage them to review their options as soon as open enrollment begins.
2. Prepare for Changes in Coverage
If Congress does not extend the enhanced subsidies, uninsured and underinsured visits could rise sharply by mid-2026. Tracking these changes early through billing data, payer mix, or appointment cancellations will help your organization plan for:
- Adjustments to charity-care and financial-assistance programs.
- Shifts in staffing or scheduling to manage new coverage gaps.
- Advocacy with local and state officials for temporary relief programs.
Providers who understand these trends now will be better equipped to maintain continuity of care for vulnerable patients later.
3. Strengthen Community Partnerships
In times of policy uncertainty, collaboration at the local level becomes essential. Partner with community organizations such as faith groups, social service agencies, food banks, and local nonprofits to reach patients who may fall through the cracks. Joint outreach events, shared referral systems, and co-hosted enrollment fairs can expand your reach and connect patients with resources like transportation, prescription assistance, or health education. Patients trust local voices. Strengthening those community ties can keep people engaged in care, even when policy decisions create confusion or fear.
Why This Matters
The ACA’s marketplaces have transformed access to care in North Carolina, cutting the state’s uninsured rate nearly in half since 2013. Losing that progress because of political gridlock would have devastating human and economic consequences.
Healthcare professionals understand that insurance coverage isn’t just about paperwork; it’s about whether patients can afford to manage their diabetes, refill their inhalers, or deliver their babies safely. The weeks ahead will test the system’s resilience, but they also offer an opportunity for providers to lead by informing, supporting, and advocating for their patients.