Mary Elizabeth Marr has had dozens of patients realize their health insurance has become too unaffordable, forcing them to change to lower quality plans or drop their coverage altogether.
As the CEO of Thrive Alabama, a federally funded, community-based clinic, she provides care to underserved populations regardless of insurance status.
One patient’s monthly insurance costs went from $200 to $400, while another’s went from $84 to $285.
One patient is contemplating leaving the country for a place where health insurance is more affordable, Marr told AL.com. Many, though, have decided to go uninsured because of the high prices.
“We survive on a very slim margin,” Marr said. “So when people start dropping off their insurance we are not going to be sustainable and we will not be here for our patients.”
Since 2021, many of the people who come to Thrive have qualified for extra federal money that comes in the form of expanded federal health care subsidies. Those subsidies were meant to lower the cost of insurance found on the marketplace created by the Affordable Care Act, often referred to as Obamacare.
But last week, the U.S. Senate rejected a plan to extend the subsidies. That leaves Alabamians who rely on the marketplace to figure out how to pay for skyrocketing insurance bills.
Premiums for individuals enrolled in the ACA marketplace could rise by an average of 93% in Alabama, according to KFF, a health policy research nonprofit. The nonprofit estimates about 130,000 people in Alabama are expected to lose their coverage if the subsidies aren’t renewed.
“That estimate is a combination of people who will no longer qualify for subsidies and people who will choose not to enroll in the marketplace because now it’s way too expensive,” said Debbie Smith, campaign director for Cover Alabama, a Medicaid-expansion advocacy group run by Alabama Arise.
Marr said one of her patients opted to drop down to a Bronze plan from a Silver plan after the plan changed from $23 dollars a month to $160. But the silver plan had a $0 deductible, while the new plan has an $8,500 deductible.
Marr doesn’t think the changes to the tax subsidies will force the clinic to close because they can rely on funding reserves for now. Instead they will likely have to provide fewer services as patients have less ability to pay.
But she’s not ready to make those plans yet.
“I don’t even want to think about it,” she said. “It’s too devastating and the work we do here is too important.”
‘Huge impact on the church’
Along with health care institutions, churches and faith centers could also be hit hard by tax subsidies expiring.
Rev. Shane Isner, a pastor at First Christian Church in Montgomery, gets his health insurance from the marketplace, as do many other faith leaders.
Baptist News reported that small congregations would be most impacted by the subsidies expiring as they typically can’t afford group plans and instead provide salary stipends for staff to use for marketplace insurance.
“All denominations are facing similar challenges related to health insurance,” Rob Fox, president of the Church Benefits Board of the Cooperative Baptist Fellowship, told Baptist News. “Beyond the potential loss of ACA subsidies, some denominational small-employer health plans are experiencing premium increases of 30% or more.”
Isner is uncertain what his costs will look like next year. It depends on how much of his housing allowance he uses and whether his wife gets a full-time job. In certain scenarios, he said, his premiums could double. Or they could go down. But he’d likely have to pay some credits back at the end of the year come tax time, he said.
But that’s not the case for much of his denomination. He says some pastors are seeing their premiums go up tenfold. His denomination is trying to help by providing a $2,500 grant for pastors who use ACA, but that won’t cover all of the costs for everyone.
“A lot of pastors like me rely on the ACA and I think this will have a huge impact on the church,” Isner told AL.com. “You’ll have less mission activity because churches need to save money, you’ll have more pastors moving around because many will probably go in search of a place that allows them to afford health care, and there will be a lot of instability, I can even see churches closing because of this.”
People in the health care industry are expected to be affected, too. About 9,100 jobs in health care could be cut if the subsidies are allowed to expire, according to Commonwealth Fund, a private foundation that supports health care research.
That’s the seventh highest amount of any state in the country, according to the foundation.
Commonwealth said their “conservative” estimate for the economic impact of allowing the credits to expire could amount to $63 million in state and local taxes and $968 million in GDP in Alabama.
“These credits expiring will have a massive impact on our state, from the economy to our health care system as a whole,” said Smith with Cover Alabama. “It impacts more than just individuals.”
Hospitals
The Alabama Hospital Association said that if the subsidies expire, “incredible financial stress” would be added to hospitals that are already operating on “razor-thin or negative margins.”
Alabama has already seen 15 hospitals close since 2011, including seven rural hospitals. Of the state’s 50 rural hospitals, 27 are at risk of closure with 19 of those at immediate risk, according to the hospital association.
Nationwide, a new study from the Urban Institute and Robert Wood Johnson Foundation found that that if Congress allows the enhanced premium tax credits to expire, hospitals, physicians, and other providers will face more than $32 billion in lost revenue in 2026.
Hospitals in particular could see $2.2 billion in unpaid bills, according to the report.
“If those subsidies expire in December…a lot of people will lose coverage. If you have that many people who become uninsured…it absolutely puts a strain on all hospitals, and it does not help our health outcomes, which are already bad,” said Danne Howard, director of the Alabama Hospital Association.
The state has some of the highest infant and maternal mortality rates in the country. Alabama has about 1,500 patients for every doctor, while a third of counties don’t have pediatricians or maternity care, and more than half of the state’s hospitals are at risk of closure.
“The long-term impact will be negative for hospitals, doctors, Alabama’s economy, and workforce,” she added.
National politics
Last week, U.S. Sens. Katie Britt and Tommy Tuberville of Alabama were among those who voted down a plan to extend the subsidies for three more years.
Britt said in a statement on X that the Democrats’ plan to extend subsidies, “props up a broken, UNAFFORDABLE system that’s wrought with fraud and failing the Alabamians who truly need it, all while extending COVID-era subsidies with no income caps.”
Both senators did, however, vote in favor of a bill that would put up to $1,500 into a health savings account for people who buy their insurance on the marketplace depending on a person’s age and income. But that proposal also failed to pass.
The same day, President Donald Trump said he would work with Democrats to find a solution on health care, but did not specify what plan he supported.
“I think we’re going to start working together on health care,” Trump he said. “I really predict that.”
The enhanced tax credits were first passed by the American Rescue Plan in 2021 – they made more people with higher incomes eligible and expanded the credits to cover more costs – and were extended through 2025 in the Inflation Reduction Act.
In 2020, 160,429 Alabamians were signed up for subsidized health insurance through the Affordable Care Act. By 2025, that number reached 477,838 people, according to KFF.
That’s nearly 10% of the state’s population.
“There’s no doubt our healthcare system is broken and affordability absolutely needs to be addressed,” said Smith. “But for the people who are about to lose their health coverage, there is a solution that’s right there. Congress can act now to help these individuals.”
Hard choices in Alabama
Adrienne Gilspie is retired from UAB Hospital and gets her insurance through UAB’s plan and Medicare. But to cover her kids, she turned to the marketplace. Two of her three children are enrolled at the University of Alabama. Her eldest, who recently graduated, has a rare condition that has put him into heart failure.
“For years the ACA has been a lifesaver for me because my kids could get full coverage that I could afford,” Gilspie told AL.com.
AL.com reviewed Gilspie’s bills from last year and projected costs for next year from her insurance provider, Blue Cross Blue Shield of Alabama.
According to the Alabama Department of Insurance, Blue Cross Blue Shield reported a 19.3% premium increase for people on the ACA marketplace, UnitedHealthcare Insurance Company reported a 20% increase and Celtic Insurance Company reported a 25% increase.
“Blue Cross and Blue Shield of Alabama understands that rising premiums are difficult for our members…when we set rates, we’re also carefully estimating next year’s healthcare costs. Uncertainty around federal tax credits and marketplace policies makes this even harder,” Sophie Martin, a spokesperson for the insurance company said in a statement to AL.com in October.
Martin added that Blue Cross, which is the largest insurance provider in the state, “remains a strong advocate for the continuation of enhanced ACA premium tax credits.”
As a military veteran, Gilspie can cover her youngest child on the VA’s student plan. But her sons, who are 23 and 25 years old, have aged out of eligibility for that program.
Her middle son’s premium will jump from $9.79 to $75.10, according to statements reviewed by AL.com.
But it’s her oldest son she’s most worried about — his monthly premium could go from $9.79 to $80 without the expanded subsidies. But, if he can’t go back to work, it could jump even higher: $533 a month.
He’s been on leave from his job because of his condition – and without an income he becomes ineligible for the subsidies altogether, and would fall into Alabama’s Medicaid gap.
If he can’t go back to work and make his salary again, she’ll have to make tough decisions about what she can afford.
“I really worry about my son and his condition,” Gilspie said. “He needs to finish his cardiac rehab so he can get back to work and be completely clear. I’m scared to cut his insurance and stop the progress he’s making or have something else happen down the line.”