By Dr. Julianne Malveaux
Congress has headed home again, leaving behind a familiar mess. Health care costs are rising, insurance premiums are climbing, millions of people are struggling to stay covered—and lawmakers have once more failed to act. This is not a surprise. These Congressional cowards love to run and hide, always leaving unfinished business, and their cowardice has consequences.
Health care consumes roughly 17 to 18 percent of U.S. gross domestic product, far more than any other wealthy nation. We spend nearly one out of every five dollars in the economy on health care, yet our outcomes—life expectancy, maternal mortality, chronic disease management—are among the worst in the developed world. That disconnect is not accidental. It is the result of policy choices, including the choice to do nothing.
One of the clearest examples is Congress’s failure to extend the enhanced Affordable Care Act (ACA) premium tax credits, sometimes misleadingly referred to as “Obamacare subsidies.” These credits lowered monthly insurance premiums for people who purchase coverage through the health insurance marketplaces. During the pandemic, Congress expanded them, making coverage more affordable for millions of working- and middle-class families, including older adults not yet eligible for Medicare, gig workers, and the self-employed.
Those enhanced credits have now expired. Not because they didn’t work—but because Congress (including Democrats) chose not to renew them. The result was immediate and predictable. Premiums rose, in some cases sharply. For some families, monthly costs increased by hundreds of dollars. Many people responded the only way they could: by downgrading coverage, taking on higher deductibles, or dropping insurance altogether. Coverage did not disappear overnight—affordability did.
This matters not only to individual households but to the entire health care system. When people lose affordable coverage, they delay care. Preventable conditions worsen. Emergency rooms absorb more uncompensated care. Hospitals, particularly rural and safety-net hospitals, face greater financial strain. Costs are shifted rather than reduced.
And, as always in the United States, the burden falls unevenly.
Health disparities are not just about biology or behavior. They are about access, affordability, and policy design. Black and Latino households, already more likely to be uninsured or underinsured, were disproportionately affected by rising premiums. Older adults aged 50 to 64—too young for Medicare but often facing higher health risks—were hit particularly hard. People with chronic conditions faced higher out-of-pocket costs or narrower provider networks.
Geography compounds the problem. Because health care is still largely administered state by state, access and affordability vary dramatically depending on where you live. States that refused to expand Medicaid under the ACA continue to have higher uninsured rates and worse outcomes. Rural areas face hospital closures and provider shortages. In effect, Americans experience different health care systems depending on their ZIP code.
This fragmentation is expensive and inefficient. It weakens bargaining power with drug companies and insurers. It creates massive administrative waste. And it normalizes inequality as a feature rather than a failure of the system.
Congress’s inaction also reinforces the growing sense that health care insecurity is something individuals must navigate alone. That framing is wrong. Health care is not merely a personal expense; it is an economic infrastructure. It shapes labor markets, retirement decisions, family finances, and long-term productivity. Medical debt remains one of the leading sources of financial stress for American households, even among those who are insured.
What makes this moment especially troubling is that we know what works. Other wealthy nations negotiate drug prices. They provide universal baseline coverage. They invest in primary care and prevention. They achieve better outcomes at lower cost. The United States does not lack technical solutions; it lacks political will.
Letting enhanced ACA tax credits expire was not an inevitability. It was a choice—one that made health insurance less affordable, widened disparities, and destabilized coverage for millions of people. Congress went home without fixing health care, but the consequences did not take a recess.
Health care policy is often discussed in abstractions—budgets, subsidies, market dynamics. But at its core, it is about who gets care, when they get it, and at what cost. When Congress chooses delay over action, inequality fills the gap.
A system this large, this expensive, and this unequal does not fail quietly. It fails in bodies, budgets, and lives. And every time lawmakers walk away, Americans are left to pay more—for less.
Dr. Julianne Malveaux is a DC-based economist and author.