Charlotte region’s low-cost, free clinics could hit capacity if ACA subsidies end
The Charlotte area’s health care system could be tested as subsidies that help tens of thousands of residents afford insurance remain in limbo.
The subsidies, provided to many people purchasing health insurance through the marketplace established by the Affordable Care Act, are set to expire at the end of the year. They were at the center of the record-setting government shutdown this fall.
Congressional Democrats spent the 43-day shutdown trying to get Republicans to negotiate an extension of the subsidies, but eight Democratic senators ultimately split with their party to pass a government funding bill without any ACA subsidy extensions in mid-November.
President Donald Trump reportedly shelved a proposal to extend the subsidies this week due to opposition from his own party.
If nothing is done before the subsidies expire and the open enrollment period for 2026 ends, advocates and experts say those who rely on the assistance could be forced to settle for worse health insurance or none at all.
That can lead to “poor health outcomes” and strain on the region’s health care system by driving people to low-cost clinics and free clinics or emergency rooms, Mecklenburg County Public Health Director Raynard Washington said.
“Ultimately, we all bear the cost of that,” he said.
What’s happening to ACA subsidies?
The ACA subsidies in question were introduced in 2021 and expanded financial help for people who get their health insurance through the federal marketplace established by the bill often referred to as “Obamacare.”
Enrollment through the marketplace “has more than doubled from about 11 to over 24 million people” since the subsidies began, according to the health policy research group KFF.
The end of the subsidies “is estimated to more than double” annual premiums for recipients, according to KFF’s analysis.
More than 975,000 North Carolinians get their insurance through the marketplace, according to KFF’s data. Charlotte-area Congresswoman Alma Adams said at a November news conference about the subsidies 88,000 people in her district rely on the program for health insurance. Her district covers a majority of Charlotte’s city limits.
Democrats in the U.S. House launched a discharge petition — a procedural move to bypass House leadership — after the government reopened to get a discussion of extending the ACA subsidies before the House. But it’s failed to gain enough signatures to move forward.
Trump delayed announcing a proposal for the subsidies this week after pushback from Congressional Republicans, MS Now, formerly known as MSNBC, reported Monday.
CBS News and The Wall Street Journal reported Tuesday GOP House Speaker Mike Johnson told the White House most House Republicans “have little interest in extending” the subsidies, “pumping the breaks on any GOP health care plan.”
What’s next for marketplace customers?
Charlotte residents who rely on the affected subsidies are already facing difficult decisions, Natalie Marles of the Charlotte Center for Legal Advocacy told The Charlotte Observer. Marles is a program manager with the group’s NC Benefits Navigator, which helps people find insurance
Her team, already downsized due to other cuts, has worked with people since open enrollment for 2026 insurance plans opened Nov. 1. And they’re already hearing from folks having to decide between moving to a plan with less coverage and higher deductibles and copays or higher premiums to keep their current plan.
“Even in the first day, we had a couple of clients that unfortunately for next year, their insurance is not going to be affordable,” she said.
She cited the example of a woman whose premium went from $0 to more than $120 for the same health insurance plan. That wasn’t affordable for the woman, so she had to switch to a lower tier, high deductible plan.
Marles is encouraging those affected to make an appointment with her team or get assistance through the marketplace itself when signing up for insurance for 2026 to navigate the ongoing uncertainty.
“At least review your options before that option is taken from you,” she said.
Potential strain on Charlotte health care systems
Marles worries many will face a choice between health care and food and shelter if the subsidies aren’t extended.
“They are in that predicament of having to chose what bills to pay,” she said.
When people have to cut their health insurance coverage or drop it altogether due to costs they can’t afford, they’re likely to miss out on critical preventative care and “essential medications,” Washington said.
“Individual’s health can be compromised pretty significantly because of cost being a barrier,” he said.
Beyond “poor health outcomes” for individuals, Washington said the impacts of fewer people having insurance can be a drag on the overall health care system.
Those who can’t afford quality insurance often have to go to low-cost or free clinics whose “resources are already limited.”
“Eventually of course they will reach capacity … Already today we have more people who need health care than what our low-cost clinics and free clinics are able to support,” Washington said.
People who can’t afford preventative care or needed medications often end up in emergency rooms too, Washington said, which increases wait times and “takes away critical resources from us being able to access them for other things that are truly emergencies.
Washington also worries about the compounded impacts of potential cuts to other programs such as Medicaid expansion.
“Any reduction in people being able to access health care in the most appropriate setting will have many of those trickle-down effects,” he said.
