Who Will Fix the Broken Health Care System?

It was Thanksgiving weekend, and Jody Crow was having chest pains. Lupus flare-ups that trigger rheumatoid arthritis and debilitating fatigue aren't unusual for Crow. She was recovering from pneumonia, and she attempted to "tough it out," crawling from the couch to a bed in her Spring Branch apartment. When she finally sought medical care, she was told she had a collapsed lung.

I'll be OK, she thought. At least I have affordable insurance.

That changed when Crow, who is self-employed and makes less than $40,000 a year, was told her monthly insurance premiums would increase from $80 to $407 a month.

Enhanced Affordable Care Act premium subsidies, created by the American Rescue Plan Act in 2021 and renewed in 2022, expired in December, meaning that up to 4 million Texans recently saw their rates double or triple, or in Crow's case, spike so high they're impossible to maintain.

Experts predict that at least 1 million Texans will drop their coverage or lose it because of new layers of bureaucracy that end automatic renewal, require more income documentation and exclude certain "lawfully present" immigrants, including DACA recipients, from acquiring insurance through the ACA marketplace.

The Texas Association of Health Plans reported in September that premiums for over 3 million Texans who rely on tax credits would jump by an average of $2,000 a year and the state's uninsured rate, already the largest in the nation, would spike from 16 percent to 20 percent, erasing years of progress.

Some Texans who re-enrolled before the December 15 deadline may be unable to make payments when the bill comes due, said Mark Jones, a political science professor at Rice University.

"They were signing up to keep the right to be able to have it but hoping that Congress would do something in December, which they did not, or in January, to reduce the payments they have to make, if not forever, at least temporarily," he said. "Realistically, if it does occur, it's going to occur as a temporary extension. And the more temporary extensions you make, the more difficult it is to end them."

Older residents and low-income families are taking the hardest hits, according to the nonpartisan think tank Center on Budget and Policy Priorities.

Crow turns 65 in May and will be eligible for Medicare. Until then, she's found a $43-per-month "bronze level" ACA option at healthcare.gov that offers fewer doctors, a higher deductible (from $5,000 to $8,000) and increased copays, about 30 percent out of pocket.

Her friends say she's the hardest worker they know and constantly offers to help others in need. In 2024, she was laid off from a roofing company that offered insurance through United.

"I knew it was guaranteed," she said of her corporate insurance plan. "The unknown is the thing that's so scary. I'm on Affordable Care Act because I can't afford health insurance. How in the world do they think that, me paying $80 a month, I'm going to be able to pay $407?"

Now Crow's paycheck depends on odd jobs: cleaning houses, organizing closets, catering small events, pet-sitting and filling in at the cash register at a friend's bookstore. If she's not working, she's not getting paid, and she's already worried about the expense of an MRI planned later this month.

"I'm working," said Crow, who was diagnosed with lupus in 2018. "I'm not looking for a handout."

Crow doesn't daydream about buying a new pair of shoes or a weekend trip to Galveston. She just wants to buy more than a bag of salad and a can of tuna when she goes to the grocery store.

"I can break down a tub of salad into five meals," she said. "I'm not trying to buy ribeye steaks. I'm talking about lettuce."

She looked into getting on her adult son's insurance but that wasn't an option. She's even thought about marrying a male friend so she could use his benefits. She's been applying for 9-to-5 jobs as an administrative assistant but says, on paper, she probably looks like someone who will be retiring soon and therefore isn't an ideal candidate.

Crow watched closely as Congress debated whether to extend premium tax credits and said she worries about hardworking moms and dads who have not only themselves but small kids to care for.

"This is scary," she said. "I don't know what tools I have in the toolbox to alleviate this fear."

Failed Negotiations

When the subsidies that capped premium costs for many Americans ended last week, insurers proposed average increases of about 35 percent or more for 2026 plans in Texas.

The changes are forcing some ACA users to choose between continuing their health insurance, buying groceries or paying rent. University of Houston political science professor Brandon Rottinghaus said affordability is on everyone's mind.

"There's a precariousness of the current economy that even a few hundred dollars a month can make a huge difference in someone's financial bottom line," he said. "This is potentially going to be that and more for a lot of people. That could be a major pinch."

Democrats in U.S. Congress attempted to extend the subsidies but couldn't reach an agreement by the September deadline, forcing a 43-day government shutdown, the longest in American history.

During the shutdown, more than 1 million Texans didn't receive food stamps on time, putting a strain on local food banks and charities. Federal government employees were expected to work for free or they were furloughed or fired.

A 35-day shutdown in late 2018 and early 2019 cost the U.S. economy an estimated $11 billion in lost productivity, according to The Guardian. Experts predict the 2025 shutdown may have cost up to $14 billion.

The government reopened on November 12 with little compromise on the spending bill, only a verbal agreement from Republicans that they would revisit a policy discussion on healthcare tax credits in January. Some have speculated another shutdown could be looming.

Economists have pointed out that the United States is in debt, to the tune of about $38 trillion, and the healthcare subsidies were put in place during COVID-19, a time when many Americans couldn't work or pay for health insurance. The subsidies were never intended to be permanent, Republicans have said.

The GOP has also maintained that the elimination of subsidies will reduce waste, fraud and abuse in the ACA marketplace and help lower federal spending levels. Additionally, they say more frequent documentation and verification processes will ensure that taxpayers are only funding health care costs for those who are truly eligible.

Unlike 40 other states, Texas never expanded Medicaid to people earning above the federal poverty level, so the ACA marketplace has been a huge driver of coverage, particularly among lower-income people, the Texas Tribune reported in July.

Medicaid is a joint federal-state assistance program for low-income individuals and families, offering broader benefits like long-term care, with eligibility and costs varying by state. Medicare is a federal program for seniors and younger people with disabilities, regardless of income, focusing on hospital and medical costs.

Medicare, which Crow is hoping will ease her health insurance woes when she turns 65 in May, still costs money, said Nancy Sims, a political science lecturer at the University of Houston.

"Don't be misled," Sims said, noting that she pays about $1,000 a month. "I pay a fortune for Medicare. It basically equals the last ACA payments I was making."

Sims said two of her friends — a woman in her 50s and a man in his 20s — were hit by the expiring subsidies. The woman, an entrepreneur, found a less expensive monthly payment through Blue Cross Blue Shield, "but the deductible is what I would consider insurmountable," Sims said.

The young man was enrolled in a cheap, basic Qualified Health Coverage plan "because he wasn't making any money."

"That's all good unless you break your foot," Sims said. Her friend recently got a job as a paralegal and will be able to get corporate insurance. But not everyone is so lucky.

None of the professors who spoke to the Houston Press offered a clear answer on what they expect to happen this month when Congress reconvenes, but it's evident that politics are at play.

Jones said there appears to be some dissension among House Republicans over what to do about affordable healthcare.

Rottinghaus agreed but said there aren't enough votes right now for an extension in subsidies.

"This will be trouble for some Republicans who are on the record as being against some of these subsidies and are part of a party that is perceived to not be as forward-thinking when it comes to helping people with big problems on their financial plate," he said.

"The reality is that fewer people will have healthcare," he added. "It's a policy choice that lawmakers are going to have to decide if they can live with. Republicans have made the case that the government shouldn't be in the healthcare business and shouldn't be subsidizing it. In a political world where affordability is the keyword, having an edge on those issues could be a plus for Democrats going into midterms."

Rottinghaus said there's time to fix the problem but compromise is in short supply during an election year.

"My sense is that the Republicans will be going into the midterms with no extension and the Democrats will have a pretty potent weapon against them," he said.

Crow says she isn't thrilled about lawmakers using affordable health care as a political chess piece.

"We're just puppets, right?" she said. "Our whole lives are being dictated by the government. Good grief. Look at those cancer patients. It's scary. I don't even know what Medicare is going to look like. It's not a golden ticket."

Texas' Struggle with Healthcare

Houston-based blogger Michelle Davis wrote on Lone Star Left last week that candidates from both political parties who have urged progressive policies on labor, education and the environment don't appear to have clear messaging when it comes to healthcare.

"For a lot of Texas Democrats, especially those who've served in the Legislature, healthcare hasn't been an abstract policy debate," she wrote. "It's been years of constituent stories about insulin rationing, untreated cancer, people waiting until the ER is their only option, and families losing everything over medical debt."

"When you govern in a state where millions remain uninsured by design, the fight often becomes about plugging holes rather than redesigning the system," she added. "That experience can push candidates toward incremental language, even when they agree with the end goal."

A lot of House Republicans are worried about the November 2026 elections, Jones said. For example, Republican Congresswoman Monica De La Cruz is an insurance agent who represents Congressional District 15 from San Antonio to the Rio Grande Valley. She's facing a competitive November election, likely against Democrat Tejano musician Bobby Pulido.

"The last thing she wants is for Pulido to be able to use the end of subsidies as a campaign issue against her in the fall election," Jones said. "And that's replicated across the country. You have 25 to 40 Republicans across the country in districts that are already known to be competitive, or if Donald Trump's approval rating continues to drop, could become competitive, and some of them are worried about this becoming a big issue in November and being used by their Democratic opponent against them."

It's advantageous for the Democrats not to extend the subsidies until after the midterms because they're more likely to keep — or flip — Congressional seats when they point out that their opponents voted against affordable healthcare, Jones said.

"The easiest compromise is probably to have a temporary one-year extension, but that's going to get a lot of resistance from Republicans who see that as being fiscally irresponsible and just delaying until next year, having to make that decision when people have become more dependent on the subsidy," he said. "Who's going to pay for this health insurance? Is it going to be these individuals or is it going to be taxpayers?"

The Broken Healthcare System

The healthcare system has some serious problems in terms of costs and coverage, Jones said.

"On average, Americans pay far more for health insurance than people in other countries but on average, have health outcomes that are notably worse," he said. "At the end of the day, someone's paying for this. Generally the subsidies are tax dollars. This is a subsidy that is primarily for the middle class. It's people who already have a level of income."

"I think one of the difficulties with these subsidies is that the government is picking winners and losers," he added. "There are two ways to look at it. One is that this is a benefit people are receiving and they don't want to pay more for their health insurance. The other is that it was a benefit that was always supposed to be temporary. I think it puts a spotlight on the fact that healthcare costs are rapidly outpacing inflation."

The government should be seeking a long-term solution, Sims said.

"The ACA went up but also a lot of people on employer health insurance are having significant increases as well," she said. "There is really no, quote unquote, affordable healthcare. Who's going to fix the broken health care system?"

The state's largest insurer, Blue Cross Blue Shield of Texas, requested a rate increase of 21 percent in 2026 for ACA-compliant individual plans, according to The Texas Tribune. A spokesperson for the company told the Tribune that the rate increases are being driven by federal changes to the ACA market and tax credit expiration.

Jones said he didn't think the affordable healthcare debate would prompt another shutdown.

"The Democrats already played that game and it didn't work out well for them," he said.

Sims said she wouldn't rule it out but added that she doesn't understand how a brief extension of subsidies would be useful if it's not retroactive to the time period since open enrollment closed.

Vivian Ho, a health economist with Rice University and Baylor College of Medicine, specializes in the study of costs and quality within the healthcare systems.

"The ACA, one reason why it's excellent coverage for low-income people, say 100 to 150 percent of the federal poverty level, is if you are at that low of a level, not only will the ACA give you subsidies to purchase health insurance, they also give you assistance so you don't have to pay a deductible, and your co-insurance rates are almost eliminated," Ho said.

The economist explained that some research shows that alternatives to the ACA's popular and now expensive "silver plan" exist so people with chronic conditions can remain insured.

An insurance company sells a plan and provides the extra benefits, and the government was supposed to reimburse the insurance company, but the Trump administration said it weren't going to do that, Ho said. A Texas law allowed the ACA plans to be restructured into something called "silver loading."

"They dramatically raised the prices of the silver plan so the government was actually going to pay for all these additional costs and in return, the insurance companies had to keep the prices of bronze plans and gold plans fairly low," Ho said. "[Nonpartisan think tank] Texas 2036 is claiming it's not going to be so bad because when the subsidies expire, you're going to have some people move to bronze plans and gold plans instead."

Two types of people are buying health insurance: those who are relatively healthy and want to protect against financial loss and those, like Crow, who suffer from a chronic illness.

"I feel for these low-income people who have serious chronic conditions and need to get expensive medications," she said. "They're going to have to go into debt. I think what the Republicans are counting on is that the majority of people will be OK because they will not have a serious health event this year."

Ho said consolidation of the nation's largest healthcare systems is driving up the cost of health insurance premiums, giving providers enormous pricing power relative to insurers.

"The government needs to stop this consolidation and they need to get more pricing information out to consumers so they are able to be more price-sensitive and choose lower-priced hospitals when they can," she said.

When premiums become prohibitively expensive, many tend to drop their coverage, heightening risk for insurance companies and further driving up premiums for those who do not receive coverage through the ACA marketplace.

Houston hospitals are making profits and building up their fund balances, Ho said, noting that the responsibility lies with the federal government to fix the broken healthcare system.

"If Congress actually started doing their work, you could see some improvement in two or three years," she said. "In the meantime, unfortunately, I think the best solution is to provide subsidies, at least this year."

A Long Road to Healing

Crow's journey with lupus hasn't been an easy one. Like many who suffer from autoimmune diseases, she believes she had it long before she was diagnosed.

Back in 2018 while working at Memorial Hermann Hospital's Prevention and Recovery Center, she went to the emergency room with chest pains and an on-call pulmonologist told her that her chart showed abnormal lymph nodes dating back to 2012.

These days, she can tell a flare-up is coming because her energy is high. When it hits, she becomes exhausted and feels disoriented. Her chest becomes tight, she has no appetite, and she loses her voice "because everything is inflamed."

"It's painful and I have zero energy," she said.

The flare-ups last about a week and occur every three or four months, she said.

For a while she took the oral chemotherapy drug Methotrexate, and the flare-ups weren't as frequent or severe. But the drug stopped working. She said she expects her lymph nodes will be biopsied again in the coming weeks and she may be put on a different treatment plan.

"It's gotten worse," she said.

There are things she can do to reduce flare-ups, like eating whole foods and limiting stressful activity, but the disease grows and spreads, and there's not a cure.

Stories like Crow's tend to be dismissed by legislators who are out of touch with the middle class, Ho says.

"Lawmakers have access to this federal employee healthcare benefit program, and it's decent healthcare," she said. "I almost feel like they should reduce the generosity of that and tell the lawmakers that they have to get Obamacare so they have to deal with the realities."

Ho said Texans who are faced with a hospital stay should inquire about the medical facility's charity care policy, information that is not usually volunteered. They should also visit the Patient Rights Advocacy website for pricing information and write to their congressperson, she said.

"Regardless of whether you get Obamacare or not, health insurance is becoming more expensive," she said. "Congress and the Trump administration are failing at their jobs. There's action they can take, and they're not taking it. They've lost touch with the average American and the affordability issues that are the most tangible. They're not willing to sit down and do the really hard work."

So is affordable healthcare a basic human right?

"Yes," Crow says without skipping a beat.

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