Spine surgeons are bracing for a shift after Democratic proposal and a Republican alternative addressing ACA subsidies recently failed to pass a Senate vote.
Senate Democrats advocated for a three-year ACA tax credit extension, and Republicans’ alternative focused on health savings accounts. Subsidies are expected to expire at the end of the year.
Spine surgeons discussed what the outcomes could spell for the specialty.
Note: Responses were lightly edited for clarity.
Question: What does the ACA vote mean for spine care over the next 12 months?
Vamsi Kancherla, MD. Specialty Orthopedics (Gainesville, Ga.): If no further legislative action is taken before January 1, (and current indications suggest that’s likely, at least in the short term), we can expect a noticeable impact on patient access to elective spine procedures starting in early 2026.
1. Higher out-of-pocket costs for patients: The enhanced subsidies have made marketplace coverage significantly more affordable for over 22 million Americans, many of whom are in the middle-income bracket without employer-sponsored insurance. Without them, average net premiums are projected to more than double (from around $888 annually in 2025 to around $1,904 in 2026 per KFF estimates), with some facing increases of 75% to 100% or more depending on age, location and income.
2. Shift to higher-deductible plans or loss of coverage: Early enrollment data for 2026 already shows trends toward patients selecting bronze-level or high-deductible plans, or in some cases dropping coverage altogether. This means higher deductibles (often $7,000 or more) and greater cost-sharing before insurance kicks in meaningfully.
3. Deferral of elective spine surgery: Spine procedures — lumbar fusions, decompressions, cervical fusions, etc. — are classic elective surgeries. Patients experiencing chronic back or neck pain often weigh the benefits against out-of-pocket exposure. When premiums rise and deductibles reset in January, many will delay or avoid scheduling these cases to avoid large upfront costs. We’ve seen this pattern historically with insurance disruptions: elective volumes drop as patients prioritize essentials.
4. Volume impact in spine practices: Over the next year, I anticipate a 10% to 20% reduction in elective spine case volume in practices heavily reliant on commercially insured or marketplace patients, particularly in regions with high ACA enrollment. This could be compounded if healthier enrollees drop coverage, leading to adverse selection and further premium pressure.
5. Broader strain on the system: Increased uncompensated care or emergency department visits for unmanaged pain could indirectly affect hospital resources, though the primary hit will be to surgical throughput.
That said, there remains some uncertainty. Discussions could resume in early 2026, and a short-term bridge or compromise isn’t impossible given the political sensitivity. In the meantime, we’re advising patients during consultations to review their 2026 coverage carefully and consider timing procedures before year-end if feasible and medically appropriate.
Morgan Lorio, MD. ISASS past president and chair emeritus of the Coding & Reimbursement Task Force: Marketplace premiums are already rising materially — I’ve seen this firsthand, with my own family’s coverage up roughly one-third. If enhanced subsidies lapse, we should expect meaningful rate shock in 2026, along with migration toward higher-deductible plans and some loss of coverage at the margins.
Out-of-pocket exposure will rise. While that increases financial pressure, some degree of “skin in the game” is not inherently negative — it can curb low-value utilization. The problem arises when cost-sharing increases without corresponding price transparency or care coordination, pushing patients to defer necessary imaging, interventions, or surgery for financial rather than clinical reasons.
Coverage churn and narrower networks will continue to create friction, not as a theoretical risk, but as a day-to-day operational reality. Eligibility changes, plan switches, and network exclusions increasingly complicate access to care, particularly in hospital outpatient settings that disproportionately serve ACA populations.
Prior authorization and medical-necessity scrutiny will intensify. This is no longer a question of if. As payers absorb higher actuarial risk, utilization management tightens, driving more denials, appeals, and administrative burden across spine practices.
Bad debt will rise, but unevenly. As patients become underinsured rather than uninsured, hospital outpatient departments will bear the brunt of unpaid balances and charity care, particularly in high-Marketplace states. Most freestanding ASCs are relatively insulated because they do not participate in ACA marketplace networks due to reimbursement and payment-risk constraints; as a result, elective ASC spine volumes driven by employer-sponsored and Medicare patients should remain largely stable.
A late legislative “patch” remains possible, but uncertainty itself is destabilizing. Practices should plan for higher friction in 2026 even if Congress ultimately intervenes.
The real saving grace of the ACA, and the strongest argument for extension or permanence, is portability. The ability to maintain coverage independent of employment matters profoundly for patients, especially those with chronic or episodic conditions like spine disease. Whatever its flaws, portability remains the ACA’s most durable and defensible contribution.
Brian McHugh, MD. McHugh Neurosurgery (West Islip, N.Y.): Regardless of what happens with the Affordable Care Act subsidies, patient costs are expected to continue rising. We are already seeing increasing premiums, deductibles, and co-insurance across many health plans. If the ACA subsidies are not extended, that trend will likely accelerate, increasing the financial burden on patients over the next year.
In spine care, higher out-of-pocket costs almost always translate into delays in diagnosis and treatment. Patients may become newly uninsured, or they may simply choose to postpone care because of rising deductibles. Unfortunately, delaying spine care allows the condition to progress, leading to greater pain, decreased quality of life, and fewer nonoperative options by the time patients finally seek treatment. Even fully insured patients may hesitate to pursue imaging, therapy, or injections if costs continue to climb.
Whether or not subsidies are extended, the broader increase in healthcare costs will require a stronger emphasis on patient education and care navigation. We will need to continue having clear conversations about treatment options and advocate for timely access to medically necessary spine care to avoid preventable disability and poorer long-term outcomes.
Christian Zimmerman, MD. Saint Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Since the original ACA was enacted 16 years ago, the insurance premiums for all Americans have increased drastically, equating to a near doubling to date. For those who were able to attain health insurance since the law, most were under the Medicare/Medicaid billet, and received care from accepting institutions. I do foresee this continuing with emergent/urgent spinal care being maintained. Current healthcare packages being touted by legislators will hopefully address the skyrocketing cost of insurance premiums to hardworking citizens and streamlining the unnecessary subsidies that are currently being maladministered. More scrutiny may arise for surgical approvals, but this is also an expectation as disparate discernment and questioning has seemingly replaced reasonability.
