Sue Dinsdale is the Executive Director of Iowa Citizen Action Network and the State Lead for Health Care for America NOW.

Politicians in Washington, D.C. are getting ready to shut down the federal government once again, despite single-party Republican control of the House, Senate, and the presidency. 

This time, disagreements in Congress over health care costs and access are preventing an agreement that would keep critical services going without interruption. 

Earlier this year, Republicans in Congress passed and President Donald Trump signed a massive budget reconciliation bill, the so-called “One Big Beautiful Bill Act,” which extended trillions of dollars in tax breaks that would otherwise have expired this year. The lion’s share of those tax breaks will go to wealthy households making over $400,000 a year and to large corporations through extra loopholes that were reinstated in the law. 

But in this vast tax giveaway, the GOP omitted one critical tax benefit that more than 20 million Americans need to lower their health costs: premium tax credits for Affordable Care Act marketplace coverage. 

Nearly half of Americans get health insurance coverage through Medicaid, Medicare, or buy private insurance through a state or federal ACA marketplace. In Iowa, nearly 137,000 people are enrolled in the marketplace. The vast majority of enrollees, over 90 percent, qualify for tax credits to help cover the cost of their premiums so they can afford the coverage. 

Thanks to Medicaid expansion and to enhanced premium tax credits, the number of uninsured people has hit a record low over the last several years by making coverage affordable even as the price of health insurance has continued to creep upward. 

But now, Trump and the GOP majority are refusing to extend the enhanced premium tax credits which expire at the end of 2025. Without a renewal or extension, 4.6 million people are expected to lose their coverage.

But that’s not all. Millions more will be forced to pay hundreds and, in some cases, thousands more for their health insurance without an extension of the premium tax credits. For example, health care costs will quadruple for individuals making just $39,142 a year, as well as families of four with combined incomes of around $80,000 a year. 

Health insurance corporations are raising their premiums, anticipating that they will lose customers due to Republicans’ refusal to renew premium tax credits, as well as a host of other Trump administration changes that limit access to health coverage. Health insurers have already announced premium hikes for 2026 averaging 18 percent–that’s the largest increase since 2017. 

The sharp hikes in premium costs will affect not just people with ACA coverage but also people who get coverage at work. Employers are bracing for their highest spike in fifteen years according to the National Survey of Employer-Sponsored Health Plans, which surveyed 1,700 companies about health costs. Those higher costs will filter down to employees and to customers as businesses struggle to stay competitive while maintaining benefits that help them retain employees. 

Democrats refuse to support any government funding bill without provisions to help Americans keep their health care. They are seeking an extension of the tax credits for 20 million people, and a rollback to Medicaid cuts from the budget reconciliation bill, which would leave another 10 million people without insurance and close hundreds of hospitals and nursing homes over the next decade. 

Republicans on the other hand, including every single Iowan in the U.S. House and Senate, refuse to take action to protect health care for millions. The outcome could be a government shutdown, starting on October 1. That would only make things worse for Americans who depend on services fully or partly funded by the federal government, like Medicare, Social Security, education, public safety, and more. 

Not only are Republicans doing nothing to make insurance more affordable, they also are doing nothing to stop the health insurance companies or the drug manufacturers from jacking up their prices. In fact, their budget reconciliation bill rewards those companies for price gouging and profiteering by lavishing them with tax breaks and loopholes that allow them to keep more of their profits. Meanwhile, average working Americans pay a greater share of their income for health care as the price of everything else—groceries, housing, transportation—is going up. 

Republicans will try to shift blame for the shutdown, but the reality is that they control both chambers of Congress and the presidency. Ultimately, they decide whether the cost of health care goes up and down, and whether the government stays open. As more and more Americans are forced to pay thousands more for health insurance, or are priced out of coverage, they will know who deserves the blame.