When America sneezes, the world catches a cold. But when the American health system catches a fever, the developing world risks pneumonia. The expiration of enhanced premium tax credits in the United States at the end of 2025 has triggered a domestic crisis with profound implications for Kenyan health policy.

In the U.S., the expiry of these Affordable Care Act (ACA) subsidies has caused premiums to spike by an estimated 114% in 2026. Millions of Americans are dropping coverage or facing financial strain. Why does this matter for a patient in Kisumu? Because a U.S. government grappling with a domestic healthcare cost crisis and an angry electorate is a government that cuts foreign aid.

The "America First" budget

The domestic pressure to subsidize American patients is diverting political will and capital away from global health. The political narrative in Washington has shifted to "taking care of our own." This directly impacts the PEPFAR and USAID budgets that keep millions of Kenyans on ARVs. As U.S. lawmakers scramble to find money to stabilize their own insurance markets, the "foreign ops" budget is the easiest target for cuts.

Kenyan policymakers are watching with alarm. The instability of the U.S. insurance market serves as a grim warning for Kenya’s own SHIF rollout: if a superpower cannot sustain subsidized coverage, can a developing economy? It reinforces the urgent need to decouple Kenya’s essential health services from U.S. fiscal cycles.

Who is Covered?

The debate over "who is covered" is now global. In the U.S., the premium spikes are forcing a re-evaluation of the social contract. In Kenya, we are having the exact same conversation. Both nations are discovering that insurance schemes without robust, sustainable financing mechanisms are destined to fail the people they are meant to protect.

• The Policy Pivot: Kenya must anticipate a leaner USAID and plan for a future where American largesse is replaced by American austerity.
• The Warning: The U.S. crisis demonstrates that subsidies are a trap if they are not permanent. Kenya’s SHIF subsidies for the indigent must be ring-fenced to avoid a similar collapse.

The global village is interconnected. The premium notice in an American mailbox is arguably the most dangerous piece of paper for the future of global health equity.