Dr. Emily Boevers is a Readlyn farm kid, now an OB-GYN practicing in Iowa and living in Waverly with her family.

On October 1, the federal government “shut down” when the prior funding resolution, which Congress approved in March with bipartisan support in the Senate, expired. This time around, the same Congress was unable to work together for a bipartisan majority to authorize ongoing funding. A central sticking point is what to do about over tax credits for health insurance, which are set to expire at the end of 2025.

A month into the shutdown, a widening chasm exists between our political leaders in Congress, with little to no progress reported. While many Americans have gone about their lives, and the government has diverted funds to cover wages for some federal employees, the stakes are getting higher as we speak.

There is nothing positive about the shutdown, and yet, as a physician, I am glad to see our representatives fighting to maintain health care coverage options for patients through the Affordable Care Act tax credits. It presents an opportunity to share insights from the history of the health care reform law and discuss the challenges of taking care of patients in our current system. Perhaps most urgently, it presents an opportunity to leverage the ongoing chaos of both our political and health care systems into what could be meaningful policy reform.

To best do that, we should take a step back to 2008, when health care reform was a top issue during the election season. The uninsured population of the United States was estimated to be 47 million people, or 16 percent of the population. This was in addition to a high number of under-insured persons: those who had insurance but faced high out-of-pocket costs, deductibles or gaps in coverage.

Access to health care raises an ethical and humanist question for many, however it is an undeniable economic issue for all of us. The heavy costs of care, particularly unplanned care, on families can translate into food shortages, housing instability and financial insecurity. On a macro level, unpaid costs in the health care system undermine the foundation of the market, limit hospitals and clinics’ ability to purchase medical technology, maintain equipment, or hire additional staff. Inequities in the ability to access and pay for health care services not only limit individual citizens’ opportunities for personal achievement when their health needs are not met, but also raise costs for those who do receive health care services.

The Affordable Care Act, enacted in 2010 and fully implemented in 2014, solved some but not all of the U.S. health care system’s challenges. One improvement was the creation of marketplaces, an online opportunity to purchase affordable insurance for those who do not have employer-sponsored coverage and are not eligible for government programs. Though health insurance plans are wildly costly to purchase individually, marketplaces offered options with varying covered benefits and cost. The law’s individual mandate to procure coverage ensured a diverse pool necessary to maintain solvency.

Initially, the Affordable Care Act was projected to reduce the federal deficit by $130 billion through its holistic approach to reform. Subsidies and tax credits offset the cost of procuring individual coverage for those with financial need.

During the COVID-19 pandemic in 2021, the Democratic-controlled Congress and President Joe Biden enacted additional tax credits, making the health insurance marketplaces more affordable than ever for people like farmers, construction workers, small business owners or employees. The Inflation Reduction Act of 2022 extended those tax credits through 2025.

Accordingly, in 2023 the number of uninsured persons in the United States shrunk to its lowest level ever, just 7.6 percent. That’s half the share of the population, compared to fifteen years earlier. While federal courts and Congress have dismantled numerous aspects of the Affordable Care Act over the years, no alternative legislation has been enacted to ensure that Americans can access health care, to control medical costs, nor to foster the necessary public health infrastructure to promote a healthy society.

This all brings me back to the shutdown. Democrats in Congress are insisting that the enhanced tax credits continue for marketplace participants. The Congressional Budget Office has estimated that without these subsidies, an additional 5 million people will become uninsured in 2026, and the out-of-pocket cost for premiums alone, not to mention actual health services, will increase by 100 percent or more for those who remain marketplace insured.

The cost to the federal government to continue the tax credits is estimated to be $350 billion over the next ten years. While our Congress continues its stalemate, I should note that open enrollment for plan selection begins on November 1. Americans who log in (starting today) will see their health insurance premiums balloon.

Challenges in health care are numerous: The increasing costs of health care are not on the ground; in fact, physician reimbursement has decreased over time relative to inflation, while supply chain costs soar and administrative teams bloat even in tiny facilities. Workforce shortages are projected to persist for the next several decades. The population—and insurance pools—are aging rapidly without adequate facilities to provide thoughtful elder care.

But for patients, the first barrier to care is having health insurance. It would be prudent to preserve ongoing access to health care until we have a Congress that will look critically at the system as a whole. The current system is understaffed, is stretched across urban and rural settings, is paid for with personal, state, and federal dollars, is reliant on tax dollars and grant dollars, is dependent on foreign supply chains, and requires strong public education to shunt students into health care careers.

Starting today, our leaders must look at this multifactorial problem and come up with strong, funded, multipronged solutions—or face the continued disintegration of the health care system.