The Obamacare Death Spiral
How a GOP-controlled Congress is preparing to let America’s health system burn
By Dr. John Petrone
This is not a warning shot. It is the countdown.
At the end of this year, Congress is on track to allow the Affordable Care Act’s enhanced subsidies to expire. Not because the policy failed. Not because enrollment collapsed. Not because the public opposed it. But because a GOP-controlled Congress has chosen to let them die.
If nothing changes, the clock runs out on the subsidies that made ACA coverage affordable for millions of Americans. And when they expire, the consequences will be immediate, predictable, and devastating.
This is what is about to happen. This is who it will hit. And this is why pretending it only affects “Obamacare people” is a lie.
What the Pending Expiration Will Do
The ACA subsidies set to expire are not minor adjustments. They are the difference between manageable health coverage and financial shock for millions of households.
Under the expanded subsidies, middle-income families qualified for help for the first time. Monthly premiums were capped as a percentage of income. Enrollment surged to record highs. Younger and healthier people stayed in the insurance pool, keeping costs down for everyone.
If Congress allows them to expire, average annual premiums are projected to more than double for many enrollees. Deductibles will rise as people downgrade to cheaper plans. Millions will face a choice between insurance and rent. A significant share will go uninsured entirely.
This is not speculation. When premiums jump sharply, healthier people leave first. The insurance pool becomes older and sicker. Costs rise again. Insurers pull back. Plans disappear. That is the death spiral economists and health policy experts are warning about right now.
Why This Will Hurt Everyone, Not Just ACA Enrollees
Here is the part congressional leaders rarely say out loud.
When millions lose coverage or carry plans with massive deductibles, hospitals still treat them. Emergency rooms cannot demand proof of insurance before stabilizing a patient. Someone always pays.
That cost does not disappear.
It shows up as higher hospital charges. Higher premiums for employer-based insurance. Reduced services and staffing cuts. Hospital closures, especially in rural communities.
Rural hospitals already operate on razor-thin margins. A surge in uncompensated care pushes many past the breaking point. When a rural hospital closes, it does not just inconvenience residents. Mortality increases. Ambulance times grow longer. Outcomes for strokes, heart attacks, and trauma worsen. Communities hollow out.
This is how a congressional vote becomes a regional health and economic crisis.
The Rural Paradox
More than half of ACA marketplace enrollees live in congressional districts represented by Republicans.
Farmers, ranchers, self-employed workers, early retirees, and small-business owners depend heavily on ACA coverage because employer-sponsored plans are not an option. These are not edge cases. They are the backbone of rural and small-town America.
And yet a GOP-controlled Congress is moving toward letting the subsidies expire. Alternative proposals have failed to replace lost affordability. Constituents are being left exposed to massive premium increases by the very lawmakers they sent to Washington.
This is not abstract ideology. It is policy that directly harms the voters who rely on it.
Why the Senate Roadblock Matters
Efforts to extend the subsidies have failed to clear the Senate’s 60-vote threshold. That is not a procedural detail. It is the mechanism through which a determined minority can block policies supported by a clear majority of the public.
Democrats pushed for a multi-year extension to provide stability and predictability. A small group of Republicans joined them. It was not enough.
Republican leadership has instead leaned on proposals centered on health savings accounts and minimal assistance for bare-bones plans. That model does not work for people living paycheck to paycheck. You cannot save your way out of premiums that are structurally unaffordable.
If Congress does nothing, the subsidies expire by design. The damage will not be accidental.
The Pattern
This fits a familiar pattern in modern conservative governance.
Starve a public program. Declare it unsustainable. Blame government. Offer privatized or individual “choice” solutions that cost more and cover less.
We have seen this playbook with public education, housing, infrastructure, and now health care. When a public system works for ordinary people, it becomes a target. When it is weakened, the failure is used as proof that it never should have existed.
This is not incompetence. It is strategy.
What Happens Next
If Congress allows the subsidies to expire at the end of the year, the real fallout will become visible when people are required to pay their first inflated premiums in 2026.
Expect enrollment drops after January. Rising medical debt. Increased emergency room usage. Insurance market exits in certain regions. Renewed calls to “rethink” the ACA rather than fix what was deliberately broken.
And make no mistake, those higher costs will bleed into employer-sponsored plans. No one is insulated from this decision.
How We Fight Back
This moment demands clarity and sustained pressure.
Understand the timeline. The damage is preventable, but only if Congress acts.
Track the votes. Names matter. Districts matter. Elections matter.
Push for state-level mitigation where possible. States can soften the blow, but they cannot fully replace federal action.
Reject fake solutions. Health savings accounts and stripped-down plans are not affordability. They are abandonment dressed up as choice.
Support serious analysis and organizing. This fight will not be won with slogans. It requires pressure, persistence, and political consequence.
If you value clear, unsparing explanations of how policy decisions shape real lives and how to fight back against manufactured crises, this work continues through paid subscriptions. The stakes are too high for surface-level coverage.
The death spiral is not inevitable. It is being chosen.
As awful as this is for all those that use the ACA, it is going to take something drastic to get those that are in the cult to wake up. When their children get sick and they have no insurance anymore, maybe they will come to their senses.
Bloody fucking MAGA idiots! We libtards are more likely than you are to have and maintain our health insurance. We are likely to be paying more income tax than you are.
AND WE BELIEVE THAT EVERYONE SHOULD HAVE HEALTH CARE SO WE ARE WILLING, MANY OF US IN FACT H A P P Y TO SEE OUR TAXES BE USED FOR YOUR HEALTH CARE.
And you elected a White House and a Congress that wants to cancel a program that is helping you afford YOUR health care.