Richmond Times Dispatch: Selective demolition of health insurance will hurt Virginia

by Prof. Chris Howard | October 20, 2025

This op-ed was published in the Richmond Times-Dispatch on October 18, 2025.

Chris Howard is the Harriman Professor of Government and Public Policy and Director of Undergraduate Studies for the Public Policy Program.

On Nov. 1, open enrollment starts for the tens of millions of Americans who get their health insurance through the Affordable Care Act marketplaces. But those who have not been watching the news closely will get sticker shock: insurance premiums that are more than double, on average, what they were last year. In Virginia, a new report finds this could be as high as an additional $1,000 per month for some families.

That's because this summer, the Republicans' One Big Beautiful Bill Act set in motion a selective, staggered demolition of health insurance, despite strong public opposition. The first blasts are about to go off, and many Virginians will be damaged unless Republican officials defuse the situation.

The selective parts of this demolition will affect the ACA marketplaces and Medicaid. In Virginia, almost 400,000 people are insured through Virginia's marketplace and 1.9 million count on Medicaid. The marketplace cuts come this year, and Medicaid will be next.

ACA marketplaces help individuals and families who are "too rich" for Medicaid but cannot afford private health insurance. In Virginia, most of them have incomes that are well below the state average. Marketplace customers are often self-employed, working for a small business, or employed by companies with unaffordable insurance. Some customers lost health insurance when they were laid off. More than 50,000 children are insured by the Virginia marketplace via their families.

To help people buy private insurance in the marketplace, the ACA created a refundable tax credit, which was temporarily expanded during the Biden Administration. As a result, millions of hard-working Americans have been able to afford health insurance. When Republicans refused to extend that expansion this summer, they effectively agreed to demolish something important without having any plan to replace it.

The nonpartisan Congressional Budget Office (CBO) estimates that ending the expanded tax credit will make marketplace insurance much more expensive, with more than 4 million Americans losing their insurance as a result. Other estimates are even higher.

In Virginia, that would mean an extra 80,000 people uninsured because they can no longer afford it. Here, a family of four with below-average income would see their annual premiums rise by $3,500. A 60-year-old couple with no kids at home and a below-average income would pay more than double in premiums, from $6,970 to $18,960 annually.

They won't be the only ones hurt. The people who remain insured will have less money available for food, shelter, and other expenses. The health care industry will be hit hard. According to the Urban Institute, uncompensated medical care in the United States will grow by $8 billion next year. Doctors, hospitals and other medical providers will lose another $32 billion in revenue from patients who no longer get care. Virginia's loss would be hundreds of millions of dollars, making hospital and clinic closings highly likely.

Most Americans, across the ideological spectrum, like the ACA tax credits. Last month, a poll by the Kaiser Family Foundation found that 78% of Americans want Congress to extend the enhanced tax credits. A large majority of Democrats and Independents are in favor, as are six out of 10 Republicans. Even most MAGA Republicans support this measure. In a polarized environment, this is one issue that unites the country.

In Washington, Democrats insist on restoring these tax credits before ending the government shutdown. It's important to point out that Democrats are not simply protecting "their" voters. Most of the people who rely on ACA marketplace insurance live in House districts represented by Republicans. Democrats are trying to help millions of Americans, no matter where they live or how they vote. Not so long ago, this was called promoting the general welfare.

A few Republicans have expressed a willingness to extend these tax credits for one year, including Rep. Jen Kiggans of Virginia Beach. Other Republicans want to negotiate later, after the shutdown ends. But Democrats feel strongly that these tax credits are good policy and should be made permanent, and they don't believe Republicans will agree to a deal without significant pressure. Given President Trump's repeated unwillingness this year to spend money that Congress had already appropriated, Democrats' desire to play hardball makes sense.

However this drama plays out, readers should not lose sight of the Medicaid cuts that take effect in 2026 and 2027. These are also unpopular with most Americans. They have the potential to harm many more Virginians than the expiring ACA marketplace tax credits. Medicaid recipients, in Virginia and elsewhere, are disproportionately elderly, disabled or children, and they are poorer than the average marketplace customers. These individuals are unusually vulnerable, and we have an obligation to take care of their medical needs.