ACA Subsidy Expiration Raises Concerns for Behavioral Health Access and ED Strain

Open enrollment for the Affordable Care Act (ACA) marketplace coverage beginning January 1 has closed, and with the enhanced subsidies set to expire, millions of Americans face potential disruptions in coverage, particularly those relying on insurance for behavioral health services. The American Journal of Managed Care^® (AJMC^®) spoke with a health systems expert to discuss what this could mean for access to mental health care.

Two bills, one to extend subsidies and another pushing for health savings accounts as alternatives, failed to advance to the Senate floor on December 11 in response to the ACA subsidies expiring at the end of this year. Despite efforts from both parties to subsidize coverage by either extending or reallocating tax credits, approximately 22 million Americans are expected to see increased premiums as early as January 1.¹ For people in need of behavioral health services, the expiration of subsidies could lead emergency departments (ED) to face increased uncompensated care burdens, said Shannon Werb, CEO of Array Behavioral Care and expert in behavioral health care systems and costs, in an interview with AJMC^®.

“Even without the subsidies changing, one of the well-publicized challenges that hospitals and health systems run into is the boarding of patients in the emergency department,” Werb said. “These patients are held in the ED under the oversight of the emergency department, awaiting the next level of care. One of the key drivers of that is waiting for psychiatric services.”

Boarding times in older adults in the ED, specifically, increased between 2017 and 2024, which has been associated with a higher risk of adverse events such as mortality and delirium, in addition to treatment delays, worse patient experiences, and loss of privacy.²

To combat long boarding times and the influx of uninsured patients seeking care, Werbs suggested health care systems partner with outpatient services like federally qualified health centers, mental health centers, and even telepsychiatry service providers like Array.

But treating and discharging patients from the ED is only half of the problem. Approximately 20% of patients seen in the ED for psychiatric care return for another psychiatric ED visit within 6 months, according to research published in Academic Emergency Medicine. These patients often have a history of severe psychiatric adverse events, lack social support structures, and have a higher prevalence of inpatient admissions and greater utilization of nonpsychiatric emergency services.³

As such, rural hospitals and health care systems are likely to experience a greater strain due to uncompensated burdens, with no current congressional legislation in place to extend or replace the expiring tax credits.

“My recommendation would be that hospitals, health systems, and community providers that are anticipating impact as a result of this think about partnerships through providers like telehealth platforms that might be able to help them to solve for some of these gaps,” Werb said.

With less than a week left in the year, House representatives are still scrambling to agree on a bill that would offer some relief from the looming increase in health coverage premiums for Americans in the new year. Yet, many are not hopeful, as there’s only a month left for people to enroll in an ACA marketplace coverage plan for 2026.⁴

References:
1. Bonavitacola J. Bills to address expiring ACA subsidies fail to pass Senate. AJMC. December 11, 2025. Accessed December 16, 2025. https://www.ajmc.com/view/bills-to-address-expiring-aca-subsidies-fail-to-pass-senate
2. McCormick B. Prolonged ED stays, boarding times among older adults underscore systemic hospital strain. AJMC. June 30, 2025. Accessed December 16, 2025. https://www.ajmc.com/view/prolonged-ed-stays-boarding-times-among-older-adults-underscore-systemic-hospital-strain
3. Singh P, Chakravarthy B, Yoon J, Snowden L, Bruckner TA. Psychiatric-related revisits to the emergency department following rapid expansion of community mental health services. Acad Emerg Med. 2019;26(12):1336-1345. doi:10.1111/acem.13812
4. Main A. Congress races against the clock to avert skyrocketing health care costs for millions. CNN. December 14, 2025. Accessed December 16, 2025. https://www.cnn.com/2025/12/14/politics/health-care-congress-bills-aca-subsidies