More than 100,000 people in SC could lose health insurance if federal help expires

COLUMBIA — Erin Johnson is scheduling as many doctor’s appointments as she can before the end of the year.

The James Island resident is among an estimated 142,000 South Carolinians expected to lose their health insurance with the end of an expanded federal subsidy that helps pay their premiums. The aid is set to expire at year’s end unless Congress approves another extension.

That would further strain the state’s hospitals, cause people to get sicker as they delay seeking care, and increase preventable deaths, advocates are warning.

For Johnson, losing the expanded subsidies means she’ll likely skip any potential follow-up appointments she needs. If, for example, her dermatologist determines she needs more treatment after removing potentially cancerous skin spots, Johnson won’t be able to afford it, she said.

“It’s actually really scary,” said Johnson, who works as a nanny in Charleston.

Subsidies under the Affordable Care Act, often known as Obamacare, have existed for more than a decade. The subsidies help pay for private health insurance plans on the online marketplace Healthcare.gov, essentially a way of signing up for coverage not provided through an employer.

More than 630,000 people in the state signed up for coverage through the marketplace, and about 95% of them used the enhanced subsidies to help pay the premiums, according to a study by the nonpartisan South Carolina Institute of Medicine and Public Health.

The subsidies are for people who make too much to qualify for Medicaid.

Before 2021, they were available for people earning up to four times the federal poverty level — which would currently be $62,600 for a single person with no children. The sliding scale of aid depended on people’s income, with those on the low end getting their premiums fully covered.

But during the COVID-19 pandemic, Congress enhanced those subsidies as part of the American Rescue Plan Act. Instead of a set amount of aid depending on income, the expansion bases aid on the percentage of a person’s income that would be gobbled up by insurance premiums.

People making up to 150% of the federal poverty level pay nothing. Anyone earning more than that can get help for any amount of their premium beyond a certain percent of their income, according to a Congressional report on the subsidies.

The enhanced subsidies also removed the income cap to qualify, newly allowing people making more than four times the poverty level to get aid. If more than 8.5% of their income would go toward health insurance premiums, they can get a subsidy to cover anything beyond that amount.

On average, South Carolinians saved between $500 and $700 each month using the expanded subsidies, according to the public health institute study.

They can get the federal aid in two ways. If they pay monthly, based on their estimated income, the subsidy acts like a coupon that subtracts from their bill. Or people can elect to pay upfront and receive a refund as part of their taxes, which is why the subsidies are also referred to as tax credits. Either way, the subsidies must be declared when they file their income taxes, according to the public health institute.

Congress extended the subsidy once before, as part of a 2022 spending package.

But a second extension is not included in Republicans’ massive federal spending package, dubbed the “big, beautiful bill,” which passed the U.S. House last month and is under debate in the U.S. Senate.

Advocates are not hopeful it will be part of the final package.

In a state that already consistently ranks among the worst in the country for health outcomes, a rise in the rate of uninsured people could have a cascading effect, advocates said.

South Carolina had more people using marketplace plans in 2025 than all but six other states, according to data from KFF, a nonpartisan nonprofit that collects health care data.

Since Congress passed the enhanced subsidies four years ago, the number of people using marketplace insurance more than doubled — a significant spike after years of declining participation, according to KFF data.

Losing the enhanced subsidies will make health care unaffordable again for a lot of South Carolinians, according to the report.

“If these go away, there’s going to be a lot of pain,” said Joel Lourie, a former state senator and CEO of insurance agency Lourie Life and Health.

As many as 380 more people could die each year because they no longer have health insurance, according to the report.

‘Really scary’

About 45% of South Carolinians have health coverage through their employer, according to the public health institute study.

But that’s not an option for Johnson, who’s been an independent nanny for the last decade.

She expects her premiums to be about $400 per month without the enhanced subsidy. And she can’t afford that on her salary of $52,000 per year, she said.

Before the expansion, Johnson didn’t have health insurance. She experienced excruciating pain from untreated endometriosis and uncertainty about her health, as two of her brothers had skin cancer lesions removed, she said.

“I was younger and didn’t care, but if anything were to happen, then I would have been screwed,” Johnson said. “But now I’m an adult, and I have responsibilities.”

If the expanded subsidies expire, South Carolina’s uninsured rate is expected to increase 34%. That’s more than double the expected national average of 16%. The change will most impact rural areas, with an expected 20% of people lacking coverage in some areas, according to the study.

Inflation in the years since Congress expanded the subsidy means people are even less likely to be able to afford to pay for the difference in premiums, the study found.

“We don’t want to go back to the times when people were deciding whether to feed themselves or buy their medicine,” said Sue Berkowitz, a lobbyist for Appleseed Legal Justice Center and a member of CoverSC, a group pushing for Medicaid expansion.

Risa Strauss, who oversees educational programs at Beth Shalom Synagogue in Columbia, said she won’t go without health insurance.

She worries too much about what might happen to her daughter and 6-week-old granddaughter if something were to happen to her, she said.

“I just know I have to stay healthy for them and for me and for the kids I work with here and for the families and the parents,” Strauss said. “There are things that we triage in life, personal things, and health care has to be a triage at this point.”

If the expansion goes away, Strauss makes just over the 400%-of-poverty cutoff, so she would lose the aid entirely.

The synagogue can’t offer its small staff health insurance, so she expects to get a so-called catastrophic health plan to protect herself in worse-case scenarios, as opposed to the plan she has now, which covers more routine care.

Even with the relatively low premium, the 63-year-old anticipates it will be double what she currently pays, racking up a bill of more than $1,000 per month for a plan that covers less, she said.

That means Strauss will have to cut back on any spending beyond the essentials, such as purchases to help the synagogue or trips to New York City to visit her new granddaughter, she said.

“Can I eat? Yes. Will I have a roof over my head? Yes,” Strauss said. “Can I live life in the modest way that I’ve been living it? No, that will absolutely change. There’s just no way.”

‘A true ecosystem’

People without health insurance are less likely to go to the doctor to address health concerns early, said Dr. Mayes DuBose, a Sumter physician and past president of the state Medical Association.

For example, someone without insurance experiencing early symptoms of developing treatable Type 2 diabetes might avoid seeking out medical treatment for fear of not being able to pay, DuBose said.

“Then, all of a sudden, you have advanced Type 2 diabetes with organ damage and all of the consequences that come from that,” DuBose said.

More severe illnesses mean more extensive and expensive treatment, DuBose said.

Providing that care, especially to people who are uninsured and can’t afford to pay, puts more of a strain on the health care system as a whole, he said.

“Health care is a true ecosystem,” DuBose said.

Hospitals will have to either absorb the extra cost or pass it onto other patients, DuBose said. If hospitals can’t make up the difference, as may be the case in rural areas, they may have to close their doors, according to the public health institute.

Fewer hospitals, or decreased demand for certain care, could mean fewer health care industry jobs. And more people with severe illnesses means more people calling in sick to work, Lourie said.

People are “going to be sick. They’re going to be unhealthy. They’re going to be out of work,” Lourie said. “It’s unfortunately going to result in a very ugly storm for the people of South Carolina, one that won’t go away quickly.”