作为联邦政府政府关门进入第十天，一个主要的医疗保健问题仍然是一个症结:保险补贴。
平价医疗法案(ACA)补贴或保费税收抵免有助于降低或消除那些通过健康保险市场购买保险的人每月保费的自付费用。
获得补贴的资格包括家庭收入和地理位置等因素。
这些补贴是奥巴马政府时期通过的最初的平价医疗法案的一部分，在新冠肺炎疫情时期得到了加强，以增加那些已经符合资格的人的财政援助金额，并将资格扩大到更多人。它们将于今年年底到期。
共和党人表示，疫情时代的扩张走得太远了，并试图说服民主党人资助一项临时支出法案，该法案没有解决即将到期的ACA补贴，并承诺稍后讨论继续补贴的方式。
众议院议长·迈克·约翰逊，洛杉矶。他认为12月31日延长补贴的最后期限还很遥远。
“那是12月31日的问题，”他在本周早些时候的新闻发布会上说。“现在有很多对话、审议和讨论，甚至两党成员都在讨论必须做出的必要改变，甚至在议会上考虑这些改变都是非常戏剧性的。但是，听着，我不会预测结果。”
然而，民主党人表示，随着ACA计划从11月1日开始开放注册，未获批准的补贴可能对数百万美国家庭不利。
约翰·霍普金斯大学彭博公共卫生学院和约翰·霍普金斯大学凯里商学院的教授梅林达·邦廷告诉美国广播公司新闻说:“民主党人已经表示，他们在摆脱关闭时期的立场是，他们希望延长并永久保留这些增强的市场溢价税收抵免。”
邦廷说:“最重要的是这些补贴，因为它们非常突出，将直接影响数百万美国人的钱包。”。
邦廷说，如果开放注册开始，这些补贴没有被批准和载入注册系统，人们很可能会看到他们的保费上涨。
估计来自国会预算办公室的数据表明，如果没有延期，对于那些参加市场计划的人来说，总基准保费可能在2026年增长4.3%，在2027年增长7.7%。
AKFF分析上个月发现，从市场上购买保险并接受财政援助的人，他们的保费平均会上涨约114%，从2025年的888美元上涨到2026年的1904美元。
税收抵免得到了广泛的支持。最近的一次KFF民意测验，该调查发现，78%的美国人支持延长增强的税收抵免，其中包括超过一半的共和党人和“让美国再次伟大”的支持者。
众议院少数党领袖哈基姆·杰弗里斯(Hakeem Jeffries)周四表示需要延长税收抵免，他说:“除非我们延长患者保护与平价医疗法案税收抵免，否则数千万美国人将经历每年数千美元的保费、自付额和可扣除额的大幅增加。”
邦廷说，这可能会影响许多美国人，特别是那些生活在医疗补助没有扩大的州的人，在市场上购买保险是他们唯一的选择。
加州大学洛杉矶分校卫生政策研究中心的研究员、加州大学洛杉矶分校菲尔丁公共卫生学院卫生政策和管理助理教授Naomi Zewde告诉ABC新闻，如果ACA补贴未获批准，低收入家庭和成年人将受到影响。
“主要是那些没有通过工作获得保险的人，他们为医疗补助挣得太多，但却不够支付每月大约600多美元一个2000到3000美元的计划免赔额，”她说。
然而，范德比尔特大学法学院(Vanderbilt University School of Law)宪法法律和健康法律及政策的大学杰出教授詹姆斯·布卢姆斯坦(James Blumstein)告诉美国广播公司新闻(ABC News)，即使补贴失效，11月1日的最后期限到来，也可以达成一项协议来追溯解决这个问题。
他补充说，他相信国会民主党人和共和党人也可以达成协议，节省ACA补贴，但不会保持疫情期间提供的全面扩张。
“我认为民主党的筹码将会减少，”他说。“共和党人已经通过了一项持续的决议，因此这个问题将在五六周内再次出现。”
Blumstein继续说，“民主党人将在五六周内再次拥有影响力，我认为无论这是否进入新的注册期，这都可以在协议中得到解决。换句话说，如果时间流逝，可以通过稍晚一点的补贴来弥补。”
本周早些时候，唐纳德·特朗普总统表示，他正在与民主党人就医疗保健政策进行谈判，并表示他愿意就医疗保健补贴达成协议，以重新开放政府。
特朗普在椭圆形办公室对记者说:“我们正在与民主党人进行谈判，这可能会带来好的事情，我说的是医疗保健方面的好事情。”。
“如果我们做了正确的交易，我会做一笔交易。当然，”特朗普在提到达成协议批准ACA补贴时说。
在一份声明中，参议院少数党领袖查克·舒默否认白宫正在与民主党人谈判。
特朗普后来收回了达成交易的意愿，在社交媒体上写作只要政府首先重新开放，他就会与民主党合作。
民主党领导人表示，除非共和党人就医疗保健需求进行谈判，否则他们不愿意投票让政府重新开放，而共和党人则表示，除非政府重新开放，否则他们不愿意就医疗保健政策进行谈判，这是一个有效的僵局。
邦廷说:“共和党人说，我们应该有一个所谓的清洁法案，只是像以前一样继续政府运作，不延长这些补贴，然后一旦我们得到了这些，我们就可以回来，我们可以谈论延长补贴等问题。”“迄今为止，民主党人似乎不愿意同意这一点，我认为这代表着正常程序的某种崩溃。”
她继续说，“民主党人看到了一个政治机会，因为有数百万人依靠这些补贴来支付医疗保险，没有什么比最后期限更能用来获得你想要的东西了。”
卫生与公众服务部的一名发言人在本周早些时候的一份声明中告诉美国广播公司新闻，民主党人应该为关闭负责。
“参议院民主党人选择保持政府关闭，将主要的医疗项目置于危险之中。他们应该做正确的事情，投票重开政府，”声明写道。
How Affordable Care Act subsidies became a sticking point in the government shutdown
As the federalgovernment shutdownenters its tenth day, one major health care issue has continued to be a sticking point: insurance subsidies.
The Affordable Care Act (ACA) subsidies, or premium tax credits, help lower or eliminate the out-of-pocket cost of monthly premiums for those who purchase insurance through the health insurance marketplace.
Eligibility for the subsidies can include factors such as household income and geographic location.
The subsidies were part of the original Affordable Care Act passed during the Obama administration and were enhanced during the COVID-19 pandemic to increase the amount of financial assistance to those who were already eligible and to expand eligibility to more people. They are set to expire at the end of the year.
Republicans have said the expansions from the pandemic era went too far and have tried to persuade Democrats to fund a temporary spending bill that doesn't address the expiring ACA subsidies, with promises of discussing ways to continue the subsidies later.
House Speaker Mike Johnson, R-La., referred to the Dec. 31 deadline to extend subsidies as being far away.
"That's a Dec. 31 issue," he said during a news conference earlier this week. "There are lots of conversations and deliberations and discussions right now, even bipartisan amongst members about necessary changes that would have to be made, pretty dramatic changes to even have that considered on the floor. But look, I'm not going to forecast the outcome of that."
However, Democrats say that with open enrollment for ACA plans beginning Nov. 1, the subsidies not being approved could be detrimental for millions of American families.
"The Democrats have said that their position on getting out of the shutdown period is that they would want to both extend and make permanent these enhanced marketplace premium tax credits," Melinda Buntin, a professor at Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Carey Business School, told ABC News.
"The thing at the very top of the list is these subsidies because they are so salient and they will directly affect the pocketbooks of so many millions of Americans," Buntin said.
Buntin said that if open enrollment begins and these subsidies are not approved and loaded into the enrollment systems, people are likely to see their premiums go up.
Estimatesfrom the Congressional Budget Office suggest that, without an extension, gross benchmark premiums could increase by 4.3% in 2026 and by 7.7% in 2027 for those on marketplace plans.
AKFF analysislast month found that people who buy insurance from the marketplace, and receive financial assistance, would see their premiums rise by about 114% on average, from $888 in 2025 to $1,904 in 2026.
There is broad support for the tax credits. A recentKFF poll,which was fielded just before the government shut down on Oct. 1, found that 78% of Americans support extending the enhanced tax credits, including more than half of Republicans and of "Make America Great Again" supporters.
House Minority Leader Hakeem Jeffries expressed on Thursday the need to extend tax credits, stating, "[U]nless we extend the Affordable Care Act tax credits, tens of millions of Americans are about to experience dramatically increased premiums, co-pays and deductibles by thousands of dollars per year."
Buntin says this could affect many Americans, but particularly those who live in states where Medicaid was not expanded and buying insurance on the marketplace is their only option.
Naomi Zewde, a fellow at the UCLA Center for Health Policy Research and assistant professor of health policy and management at the UCLA Fielding School of Public Health, told ABC News that working low-income families and adults will be affected if the ACA subsidies are not approved.
"Mainly those who don't get insurance through their job, who make too much for Medicaid but not enough to pay[about] $600-plus per monthfor a plan with a two-to-three-thousand-dollardeductible," she said.
However, James Blumstein, university distinguished professor of constitutional law and health law and policy at Vanderbilt University School of Law, told ABC News that even if the subsidies lapse and the Nov. 1 deadline arrives, a deal could be worked out to retroactively fix the issue.
He added that he believes congressional Democrats and Republicans could also come up with a deal that saves the ACA subsidies but doesn't keep the full expansions that were offered during the pandemic.
"I think the leverage for the Democrats will diminish," he said. "Republicans have passed a continuing resolution so that this issue is going to come back up five or six weeks again."
Blumstein continued, "Democrats will have leverage again in five or six weeks and I think that whether this goes into the period of new enrollment or not, that can all be fixed in the deal. In other words, if the time lapses that can be overcome by the subsidies coming a little bit later."
Earlier this week, President Donald Trump indicated that he was negotiating with Democrats on health care policy and that he was open to making a deal on health care subsidies in an attempt to reopen the government.
"We have a negotiation going on with the Democrats that could lead to good things, and I'm talking about good things with regard to health care," Trump told reporters in the Oval Office.
"If we made the right deal, I'd make a deal. Sure," Trump said in reference to making a deal to approve ACA subsidies.
In a statement, Senate Minority Leader Chuck Schumer denied that the White House was negotiating with Democrats.
Trump later walked back his willingness to make a deal,writing on social mediathat he would work with Democrats as long as the government is reopened first.
Democratic leaders have said they are not willing to vote to reopen the government unless Republicans negotiate on health care demands, while Republicans have signaled unwillingness to negotiate on health care policy unless the government is reopened -- an effective stalemate.
"Republicans are saying that we should have what is referred to as a clean bill, just continue the government operations as they were, without extending these subsidies, and then once we've got that, then we can come back and we can talk about things like extending the subsidies," Buntin said. "Democrats are seen so far unwilling to agree to that, which I think represents a sort of breakdown in normal process."
She continued, "Democrats are seeing a political opening, because there are so many millions of people who depend on these subsidies to be able to afford health insurance, and there's nothing like a deadline to use to get something you want."
A spokesperson for the Department of Health and Human Services told ABC News in a statement earlier this week that Democrats are to blame for the shutdown.
"Senate Democrats are choosing to keep the government shut down, putting major health programs at risk. They should do the right thing and vote to reopen the government," the statement read.
