How the fight over health care is going to shut down the government

With the government running out of funding at midnight, the fight in Washington has narrowed to a single issue: health care. Democrats are refusing to back a short-term spending bill unless it extends the enhanced Affordable Care Act subsidies that were expanded during the pandemic and are set to expire at the end of the year. Without those subsidies, millions of people who buy coverage through the ACA marketplace could see their premiums rise sharply in January. Democrats are also pressing to undo recent cuts to Medicaid eligibility and work requirements, and they want to limit the administration’s ability to redirect health funds without congressional approval.

Republicans, by contrast, are insisting on a “clean” continuing resolution that keeps funding at current levels through mid-November while leaving health policy fights for later. They argue that attaching policy riders to the stopgap bill risks derailing it altogether and say Democrats are holding the government hostage to achieve their health agenda. President Trump has echoed that message, while threatening layoffs in the government workforce if the shutdown occurs.

The standoff has real consequences for health agencies if funding lapses. While core programs such as Medicare and Medicaid benefits would continue, the Department of Health and Human Services estimates it would furlough about 41% of its workforce, or roughly 32,000 employees. The National Institutes of Health could suspend new patient admissions into clinical trials, and the Centers for Disease Control and Prevention would be forced to send home nearly two-thirds of its staff, slowing disease surveillance and public health programs. At the Centers for Medicare & Medicaid Services, about half of employees would continue working, but oversight and regulatory work would be curtailed.

The Food and Drug Administration is better positioned, with the majority of staff funded through industry user fees, but even there, non-essential operations could be paused. The ripple effects would extend to providers and patients. Hospital-at-home programs and telehealth services that rely on congressional authorization could lose reimbursement if a deal is not reached, forcing seniors and chronically ill patients back into hospitals or clinics.

Talks over the past 24 hours have done little to bridge the gap. A White House meeting with congressional leaders ended without progress, and Senate Republicans are now planning multiple procedural votes on their funding measure in hopes of forcing Democrats to back down. Democrats, however, remain adamant that health protections must be secured now, warning that waiting until the end of the year would expose families to sudden premium hikes and destabilize the insurance markets.

The stakes are immediate: if no deal is reached before midnight, government funding will lapse, research projects will grind to a halt, thousands of health workers will be furloughed, and patients could begin to feel the disruption in clinical care and public health services.