Rachel LaCasse-Ford, right talks to Sen. Tammy Baldwin about her use of the Affordable Care Act marketplace to buy insurance during a meeting Baldwin held with small business owners and others in Mount Horeb, Wisconsin, on Sept. 25. (Photo by Erik Gunn/Wisconsin Examiner)

Matt Raboin owns Brix Cider, a farm-to-table restaurant, and brews apple cider in the Dane County village of Mount Horeb.

His wife’s full-time job with benefits provides the family with health insurance, but for Raboin, the Affordable Care Act (ACA) has made an important difference for some of his employees.

“We don’t offer insurance ourselves,” Raboin said during a recent round table discussion set up by Sen. Tammy Baldwin (D-Wisconsin). “A lot of small businesses in small towns aren’t in a financial place to do that.”

Like Raboin, some of his employees get their coverage through a spouse or because they also work another full-time job that provides benefits. But over the years, the ACA and the HealthCare.gov marketplace created under the law have been a critical source of health coverage for many of his employees, Raboin said.

Recently he polled a number of them. One memorable response came from a part-time employee who also has a part-time job with a local church. She buys her health insurance on HealthCare.gov. Thanks to an increase enacted in 2021 in tax credit subsidies, she’s been able to afford the premiums, Raboin said she told him.

“So without it, she’s like, ‘I can’t keep working for you. And I don’t think I keep working for my church. I think I have to find a different job,’” Raboin recalled.

The ACA and HealthCare.gov have made it possible for millions more Americans and thousands more Wisconsin residents to obtain health insurance.

But less visibly, the health care marketplace that the ACA created has also helped support many small businesses. If the enhanced tax credit subsidies that lowered the cost of health insurance for millions over the last three years aren’t renewed, small business owners and employees say they could be especially hard hit.

Nearly half of people who get their health insurance through the HealthCare.gov marketplace are self-employed or small business owners, or else work for small businesses, according to KFF, an independent nonprofit that researches and reports on health policy.

To expand access to health care, the ACA created the HealthCare.gov marketplace to make buying health insurance easier for people whose jobs don’t provide coverage and who don’t qualify for government programs such as Medicaid.

To make coverage more affordable, the law provides tax credit subsidies for people with incomes up to 400% of the federal poverty guideline. Those subsidies were increased in 2021 and expanded to people with higher incomes.

The enhanced subsidies will expire at the end of 2025 unless Congress extends them — driving up the cost of health insurance for millions.

The enhanced subsidy “saves more than 230,000 Wisconsinites an average of $500 every single month,” Baldwin said during a Zoom press conference Tuesday.

For Chrysa Ostenso and her late husband, the enhanced subsidies lowered their premiums from nearly $2,000 a month to about $300 a month, Ostenso said.

Ostenso lives in Ladysmith, Wisconsin, where she and her husband operated an optometry clinic for more than three decades, raising four children along the way.

“We always struggled to afford health insurance but of course we had to buy it,” Ostenso said in an interview. “As a family of four kids with a small business, you can’t go without health insurance.”

The family’s high deductible plans required them to pay $6,000 a year out of pocket before insurance would cover their health care. By 2020, when the children were grown and the health plan just covered Ostenso and her husband, they were paying $1,979 a month, she said.

They hadn’t qualified for the original ACA subsidies. When the enhanced subsidies were enacted in 2021, however, Ostenso said their premiums went down to $300 a month, increasing to $500 a month in subsequent years.

“It actually meant freedom to go to the doctor, because we were spending so much money on our premiums [previously] that we actually couldn’t afford to go to the doctor,” she said.

Standoff over extending subsidies

In the weeks leading up to Tuesday night’s federal shutdown, Democrats in Congress demanded that Republicans rescind sweeping changes to Medicaid that were part of the major tax- and spending-cuts megabill that President Donald Trump signed July 4.

They also demanded an extension of the enhanced ACA subsidies.

Baldwin has coauthored legislation that would make the enhanced subsidies permanent. She spent part of the just-concluded congressional recess traveling Wisconsin and meeting with people who expect to see their health costs go up sharply if the increased subsidies end.

During Tuesday’s press conference, Baldwin related a conversation with a  bakery owner who worried about how she and her family will afford health insurance, “but also that increased costs on the [HealthCare.gov] exchange will mean that her employees at her bakery may have to quit to work for big companies that offer insurance.”

During Baldwin’s press conference, Gigi Gastevich, an artist who owns a retail space in Stoughton, said the ACA and the enhanced subsidies had made it possible for her to launch and grow her business.

Gastevich is a 15-year cancer survivor. When starting her business, she qualified for BadgerCare — Wisconsin’s main Medicaid program — which covered the ongoing medical monitoring she requires as a cancer survivor.

In 2025, with her income above the limit for BadgerCare, she found an insurance plan on HealthCare.gov that included her existing health care professionals in its network and had an affordable deductible.

The plan’s premium was $481 a month, Gastevich said, but the enhanced subsidy  brought it down to about $100 a month.

Without the subsidy, she said, she will have to switch plans — possibly losing her long-standing group of providers if they aren’t in the network. She said her choices include taking a high-deductible plan that would put some of the regular care she’s been recommended as a cancer survivor out of reach financially; or closing down her business. 

“[That] would mean not only abandoning my dream of entrepreneurship and being a self-employed artist, but taking away an income source for the dozens of artists and artisans whose American-made work I sell here,” Gastevich said.

It would also forestall her plans to scale up her business to sell her own line of textiles and employ others. “I won’t be able to do that if my health and well-being is tied to being on an employer-based health care plan,” she added.

Uncertain future

During her tour of the state, Baldwin stopped in Mount Horeb on Thursday, Sept. 25, where she spoke with Brix owner Matt Raboin and four other business owners as well as local health care providers.

The round table took place at the Upland Hills Health Mount Horeb clinic. The urgent care clinic is part of a broader system that includes a hospital in Dodgeville and clinics in surrounding communities.

Dr. Mark Thompson, Upland Hills CEO, said system executives expect to see about $400,000 a year in additional uncompensated care based on projections of people leaving the insurance rolls because they don’t think they can afford the new ACA premiums.

Jay Goninen sat in as a board member of the Upland Hills system, but he’s also an employer for whom the ACA has made it possible to provide health benefits.

Goninen owns a business that helps connect the auto repair industry with high schools and technical schools. For the last few years, he’s opted to have employees of the firm purchase health insurance on the ACA.

The company pays a portion of the cost. Goninen likens the arrangement to a common practice of employers who offer a group health plan and split the cost with their employees.

“I do really worry about just the individual person and their ability to afford to live right now, in general,” he told Baldwin. “It is tough.”

In addition to worrying about what will happen to employees who bought coverage at HealthCare.gov if they lose their subsidies, Raboin said he’s also concerned about the broader ripple effect in the community.

“Our clients aren’t rich,” Raboin said. “Not everybody can go out to eat all the time, and if you start taking away that expendable income, that’s less people coming out to eat. So I think it would depress the whole economy.”

Rachel LaCasse-Ford owns a campground with her husband and also heads the Mount Horeb Chamber of Commerce.

“I’ve never really had a job that offers health care,” LaCasse-Ford told Baldwin. “I’ve always worked in small business, so we have always used health care from the ACA.”

The enhanced tax credits “definitely benefited” the couple, she said. “And if those go away, that will make our budgets tighter, and it will make things more challenging for us.”

With every new job, LaCasse-Ford said, she considers its impact on their health coverage and whether she can stay with a nonprofit employer such as the chamber, work for a small business, “or if I need to look for a larger employer that offers benefits.”

University of Wisconsin-Madison Professor Lingjun Li, left, and Ph.D. candidate Lauren Fields show off some of the crabs used in Fields' research project on how neuropeptides relate to feeding. The NIH, which funded the project, canceled it in April. (Photo courtesy of Lingjun Li)

Lauren Fields was less than four months into a research project funded by the National Institutes of Health (NIH) when she got an email message from her program officer at the federal agency.

A doctoral candidate in chemistry at the University of Wisconsin-Madison, Fields has been studying the biochemistry involved in the feeding process of  a common crab species. She and her faculty supervisor believe the project can shed new light on problems such as diabetes and obesity in human beings.

The two-year research project started in early January 2025. But the April NIH message told Fields the funding was being cut off. It didn’t explain why.

“It just said changes to NIH/HSS policies and priorities,” Fields says. NIH operates under the umbrella of the federal Department of Health and Human Services (HHS).

Fields contacted her program officer on April 9. “I tried to kind of probe further with my program officer and I didn’t get any further than that,” she says.

She and her project supervisor have a working hypothesis, however. Fields’ project was funded under an NIH program to ensure that more researchers come from backgrounds that have been historically under-represented and underserved. She won the award as a native of Appalachia and a first-generation college student. 

This past spring, that program was quietly shelved after an executive order from President Donald Trump on his first day in office put an end to all federal programs involving diversity, equity and inclusion.

Trump’s order called such efforts “radical and wasteful.” But Fields’ supervisor, UW Professor Lingjun Li, says measures to broaden the field of researchers can help ensure higher quality and more useful research findings.

“We believe that different, diverse backgrounds can actually bring unique and different perspectives to make our research enterprise better and stronger,” says Li. Li is on the faculty at the UW School of Pharmacy as well as at the Chemistry Department in the UW-Madison School of Letters and Science.

Feeding crabs to understand human biochemistry

Fields’ project examines the feeding behavior and process in the Jonah Crab, widespread in the coastal waters of North America. She wants to know how neuropeptides — molecules that send signals through the nervous system —  prompt them to start and stop feeding.

“Crabs actually have one of the most well characterized systems to understand feeding behavior in the animal kingdom,” Fields says. That’s why UW has been making use of the species in its research.

Fields says research such as hers is directly relevant for human conditions that relate to eating — “anorexia, obesity, diabetes — conditions like that.”

For example, the medication semaglutide, which includes the high-profile brand Ozempic and is used for diabetes control and to curb obesity, is understood to work by mimicking the neuropeptides involved in the human feeding process.

Thanks to similarities between the neurotransmitters in crabs and the neurotransmitters in mammals, researchers can use what they learn “from our humble crabs to understand feeding behavior in higher order organisms,” she says — including people.

The project as it was designed also made it possible for Fields to track the entire research process instead of it being spread out through several different labs. That’s not always possible, she says.

“So I do feed the crabs,” Fields says. “I do dissect the crabs and prepare the samples from the tissue and all the way through.”

She records mass spectrometer readings that produce relevant information about the neuropeptides at the center of her research, then analyzes the data at the end to make sense of the whole feeding process.

A personal connection

Fields feels a personal connection to the research because of where she grew up. “Appalachia has historically higher rates of diabetes and heart disease, also mental health disorders, and it’s also been kind of really impacted by the opioid epidemic,” she says. “These are things that I grew up with, that’s a very real part of my everyday experience.”

And that background “is something that I keep in the back of my head,” Fields says. “Even on a hard day, it tells me what I’m working towards is helping the people back home overcome these types of things and have new alternative solutions that are maybe more affordable.”

Fields’ project was funded through an NIH fellowship program known as F-31,  directed at pre-Ph.D. researchers, and a specific category within that program set aside as diversity awards.

According to a now-expired NIH description, the F31 Diversity awards were made “to enhance the diversity of the health-related research workforce by supporting the research training of predoctoral students from diverse backgrounds including those from groups that are underrepresented in the biomedical, behavioral, or clinical research workforce.”

In her own research field, examining Alzheimer’s disease, Li says there’s “abundant evidence”  that the condition affects different ethnic groups differently — both in the outcomes it produces and in the biomarkers that are used to track the progression of the illness in a patient.

“The intention is to really help to address some systematic inequities in biomedical research,” Li says.

A more diverse research workforce can elevate the importance of considering a more diverse group of patients, helping researchers “really get a full understanding of the disease,” she says. “And there’s a lot of talk about precision medicine, personalized medicine and certain types of treatment that will be more effective to certain populations than others.”

Fields says that to qualify for the diversity research grant, “you have to jump through several hoops to really illustrate to them that you are somebody that has faced challenges that would warrant the diversity fellowship.”

But the academic qualifications are no less rigorous than what the regular F-31 grants require, she adds. Fields first applied in December 2023 and went through the process of refining the application before it was finally approved. The funding officially began in January 2025.  

“You have to be in the very strict, top percentage of the applications that were submitted to even get funded,” Fields says. The sudden decision to cut her project short leaves “a message that has been kind of hard to swallow.”

A short-term reprieve

Fields did get a short-term consolation: While the project was canceled in April, she was told her funding for the current calendar year, $37,165, remained intact through December. But she was also told that the funds “can be terminated even earlier, which fortunately has not happened,” she says.

She has been able to continue the project, but she’s also had to accelerate it considerably.

“It’s now, OK, we need to hurry up and do the research with the time that we’re allotted,” Fields says — even as she has to watch over her shoulder in case the money is cut off sooner. “You have to move as fast as you can, or as efficiently as you can, because you don’t know when the rug is going to be pulled out from under you.”

The prospect of other funding to make up for the second year loss, also $37,165, is unlikely.

“That was a conversation that we’ve had several times along the way,” says Fields. “When I found out that it was terminated [NIH officials] said, ‘Oh we would love to help you apply for other opportunities,’” she recalls.

Considering how much time elapsed between her original application and the grant’s arrival, however, “it’s a little tricky,” Fields adds. “I think they were really just trying to be supportive, but at the same time, not super practical.”

Private funding seems an unlikely prospect, Fields and Li say, with competition escalating while federal options are being curtailed.

“Research funding in general is a lot more difficult to get,” says Li. “It’s pretty hard to find replacement funding right away.”

In the meantime, Fields’ next step is to seek a post-doctoral fellowship — a task made more challenging because of widespread academic hiring freezes prompted in the wake of federal research funding cancellations.

She still has her eye on a career in academia, where she hopes to pursue research on personalized medicine for people in Appalachia.

Li says Fields is far from alone in her experience. Some colleagues across the country who were awarded fellowships through the diversity program saw their awards canceled “either right before or just a couple of months after when they started,” Li says, and their projects have ended before they even started.

“There are quite a few people. A range of research groups and programs are being affected,” Li says. “This could have even a longer-term impact on our country’s biomedical research.”