The 59-year-old retired teacher, who recently moved from Ohio to Michigan, now pays $341 a month for a pair of plans, one that covers routine and urgent care and another that pays fixed amounts for hospital stays. Neither meets federal standards for comprehensive coverage.

Though she practices yoga and is healthy, Miller said she still feels “vulnerable.” If she lands in the hospital, her plan pays a flat $2,000, a fraction of the of an average hospital stay.

“I don’t gamble. But I may as well,” she said. “This is gambling.”

Congress’ decision late last year not to extend enhanced marketplace tax credits has boosted the appeal of alternatives to comprehensive insurance — plans like Miller’s, which have lower premiums but don’t meet ACA standards for coverage or consumer protections. Unlike plans sold on the exchanges, these options — some sold by major insurers, others by small companies or nonprofits — can deny claims with few or no legal rights for consumers to appeal. The plans are not required to cover “essential health benefits,” such as preventive care, and can impose annual or lifetime caps on benefits.

There is debate over whether these options help or harm patients. Consumer advocates dismiss them as “junk insurance,” while proponents say restricting alternatives to pricey marketplace plans risks driving up the number of uninsured. Some states, including Kansas and Florida, and the federal government itself have eased regulations on such plans or created incentives to join them, while other states, including California and Massachusetts, have tried to deter enrollment in alternative insurance. Those regulatory guardrails, however, are now being stress-tested as premiums blow out household budgets.

Alternative insurance takes many forms, including short-term policies, which were designed to bridge temporary gaps in coverage and often exclude preexisting conditions, and fixed-indemnity plans, which pay a flat rate per service regardless of how high costs go and are intended for supplemental use. Arrangements in which people pool their money to cover one another’s bills, including faith-based “healthcare sharing ministries,” also provide a cheaper alternative to the marketplace options. Because they are not considered insurance under federal or state law, they are not legally bound to pay for even .

Enrollment data for alternative plans is mostly confidential, but several indicators point to shifts in the market. Recent estimates suggest marketplace enrollment from 2025, and a of people on the exchanges last year found that 5% switched to private, nonmarketplace individual coverage, including plans that don’t comply with the ACA. Covered California, the state’s marketplace, plans to survey former enrollees to find out where they went.

Insurance industry insiders also report that, amid the expiration of subsidies, alternative plans are making a marketing push. Colorado insurance broker Samantha Albritton said that before ACA open enrollment, she saw more marketing from fixed-indemnity plans than in previous years. One healthcare sharing plan, Zion HealthShare, had more than 75,000 members in February — a 50% increase since last June, it said in a statement.

Critics of these alternative plans say the major issues occur when people use them as primary insurance and don’t realize the coverage is inadequate until they need it most. “Humans have bodies that can fail them,” said Amy Killelea, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms.

This <a target="_blank" href="/health-industry/alternative-health-plans-growth-sharing-ministries-short-term-aca-premiums/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Sign-ups were already down in January by about from last year’s . For this year, enrollees then faced premiums that increased, on average, . On top of that, subsidies that help people purchase coverage shrank or vanished.

Now experts are watching how many of the approximately 23 million people who enrolled will fail to pay their share of premiums.

While available data on premium payments is mainly from January, a few states that run their own ACA markets have released information for later months. The sharpest drop in people paying premiums, based on limited data, is , which saw a 28% drop in April compared with the same period a year ago, according to an analysis by Charles Gaba, a healthcare policy analyst and blogger who specializes in the ACA.

The news website NOTUS that it had internal Centers for Medicare & Medicaid Services data showing that roughly 21% of people using the federal ACA marketplace — — failed to pay their share of January premiums, which, if correct, is far higher than at the same time last year.

CMS did not answer questions from Ñî¹óåú´«Ã½Ò•îl Health News about the enrollment data.

In looking at the early numbers analysts released, “we can’t yet quantify how much worse it will be than in previous years, but it will absolutely be worse because of the sticker shock,” said Ellen Montz, a managing director with the Manatt Health consultancy, who helped oversee the ACA during her tenure with the Biden administration.

The initial results come amid rising public concern about affordability, that are often .

A KFF analysis , for instance, found that the average ACA plan deductible saw the steepest increase in history — growing by 37%, or over $1,000, from $2,759 in 2025 to $3,786 in 2026 as enhanced premium tax credits expired.

Those rising costs pose a political challenge for President Donald Trump and the broader GOP, which has opposed enhanced subsidies to help people purchase Obamacare coverage. Republican lawmakers also passed a spending package last year — enacted as the One Big Beautiful Bill Act — that included provisions expected to reduce ACA enrollment and fueling higher premiums this year.

The enrollment reductions “are real people with real consequences,” Montz said. “The Affordable Care Act is a political lightning rod, but it’s a critical component of the coverage landscape.”

Following the Numbers

Right now, the drop-off rate aligns with what some policy experts predicted, partly because Congress did not extend generous benefits that expired at the end of last year. Those enhanced subsidies had been in place since 2021.

“Overall, the individual market does appear to be trending toward a significant contraction in 2026, and may well resemble” drops projected by the , said a , an analysis arm of the HMA Co.

Based on its analysis, drawn from data provided by 75 insurers, Wakely estimates that average ACA enrollment will end up being 17% to 26% lower this year than last.

So far, the Wakely report says, an average 86% of enrollees made their first payment in January.

Failure to pay premiums varied by state. Those with the lowest drop-off rates had enacted additional help — such as backfilling part or all of the reduced subsidy amounts with state money — or experienced lower premium increases. States that run their own exchanges had higher payment rates (92%) than those served by the federal marketplace (82% to 84%).

Gaba’s initial analysis of data includes more recent numbers from nine of the 20 states that run their own Obamacare marketplaces.

“Georgia could be fairly representative” of other states that did not enact additional protections, Gaba said. For example, payment failure rates, year over year, were 11.6% as of April in New Jersey, and, as of February, 15.7% in Washington state and 8.5% in California.

Only one state in his sample — New Mexico — saw an increase in the percentage of people making premium payments, according to the latest available monthly data. Unlike most, it to fully make up for the lower federal subsidy amounts.

Enrollment figures for the ACA are never static. Traditionally, more people sign up — either through auto reenrollment or by taking initiative to shop — than actually pay premiums, so the numbers tend to be higher at the start of the year.

People drop out over the course of a year for many reasons, such as finding other coverage through a job or by marrying someone with insurance.

Cost, of course, is a factor. This year, because premiums went up and subsidies went down, many people faced what they previously paid toward their coverage.

And the Trump administration ended a special enrollment program that let low-income people enroll year-round.

drops should not be seen solely in the context of rising costs. Paragon Health Institute, a free-market think tank that has become influential among conservatives on Capitol Hill, has long argued that record enrollment numbers in recent years were fueled by fraudulent sign-ups, perhaps in the millions.

, , and policy experts took issue with the methodology Paragon used to estimate improper enrollments, saying they likely were vastly overestimated.

In a , the organization’s president, Brian Blase, doubled down on the fraud findings. Using data that detailed how many people failed to make premium payments each year, on average, from 2014 to 2019 — the year before covid emerged and two years before enhanced subsidies kicked in — he offered this prediction for 2026: About 19 million people would be enrolled by year’s end. Even at that, the note says, the “market would be 90% higher than the pre-COVID average.”

For other experts, however, the biggest explanation for falling enrollment is cost.

Some people had never experienced the ACA before the enhanced tax credits kicked in, so they faced extra sticker shock.

“In economic theory, no matter whether one is left, right, or center, it’s a simple fact that when you raise prices of something, fewer people will buy it,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

The Long View

The expectation of a lower enrollment trend holding up is one of the key factors likely to translate into higher cost estimates as insurers draw up 2027 rates.

For one thing, though it is still unclear how many people will stay enrolled, it is also unknown whether those enrollees will submit more medical claims than insurers projected. It’s generally thought that younger or healthier people are more likely to drop coverage when faced with growing premiums.

Secondly, there has been a sharp shift by consumers to purchase bronze-level plans, which have smaller monthly premiums but higher deductibles — the amount people must pay out-of-pocket for most treatment, except preventive care, before insurers pitch in. The found that sign-ups for bronze plans jumped from 30% to 40% of total plan selections — growing from 7.3 million in 2025 to 9.2 million people this year. Will they pay? Or will hospitals and doctors be on the hook for uncollected copays or deductibles, and then raise prices to compensate?

Insurers base their premiums, in part, on such analyses.

Another troubling factor for actuaries is the late posting of a key regulation that sets the next year’s rules for ACA health plans. The initial 2027 proposal from the Trump administration came out in mid-February and included aggressive new ideas — such as sharply increasing deductibles for certain types of ACA plans or allowing insurers to offer plans with no set networks of medical providers. It was , well into the time when insurers are calculating premiums for the following year. Many of the proposed changes, with some modifications, were approved, such as allowing for higher annual deductibles in some types of coverage.

“This is definitely a challenging year to be an actuary,” said Louise Norris, a health policy analyst for healthinsurance.org, a consumer information and referral website affiliated with Trove Group, an insurance agency.

“We know for sure that the individual market has gotten smaller and almost certainly sicker, as the people dropping coverage are more likely to be healthy.”

While they “aren’t waving huge red flags” yet, insurers are closely watching trends, said Michelle Anderson, a director at Wakely and co-author of the recent report.

Anderson does not expect an average 26% premium increase like the one seen this year.

Still, Anderson expects the ongoing uncertainty and predicted decline in enrollment, which will vary by state and insurer, to play a role in setting next year’s premium rates.

“It would not surprise me if there were some double-digit increases,” Anderson said.

Ñî¹óåú´«Ã½Ò•îl Health News reporter Rachel Spears contributed to this article.

This <a target="_blank" href="/insurance/eroding-aca-enrollment-higher-insurance-rates/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Read more coverage from our “Bill of the Month,” “Health Care Helpline,” and “Priced Out” series:

• “How To Make a High-Deductible Health Plan Work for You,” by Jackie Fortiér.
• “To Avoid Care Disruptions, Know When the Clock Runs Out on Your Prior Authorization,” by Sarah Boden.
• “So Your Insurance Dropped Your Doctor. Now What?” by Bram Sable-Smith.

This <a target="_blank" href="/insurance/watch-8-health-insurance-terms-you-should-know/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

More than 80 of his customers who were enrolled in the same Medicare supplemental plan from the insurer Chubb got hit last August with a 45% increase.

“In my 49 years of doing biz as a broker, I’ve never seen a premium increase be effective immediately on everyone, instead of on their policy anniversary,” said Jaggi, whose brokerage scrambled to find more affordable options for clients. The policies pick up deductibles and other costs not covered in traditional Medicare, and without one there is no upper limit on how much a consumer might owe each year.

While 45% was an unusually big jump, Jaggi and other brokers say double-digit premium increases for Medicare supplemental, or Medigap, policies are becoming the norm.

A Chubb spokesperson did not respond to requests for comment on the increase.

More than 12 million people — of those in traditional Medicare — buy a Medigap policy. Others rely on some sort of retiree employer coverage or a different backup. About 13% of people in traditional Medicare don’t have supplemental coverage, according to KFF, meaning they could be vulnerable to large costs if they have a serious illness.

In the supplemental market, following big increases last year, rates appear to be rising again. In early 2026 filings with state insurance commissioners from Aetna, Blue Cross Blue Shield, Cigna, Humana, Mutual of Omaha, and UnitedHealthcare, rate increases for Plan G policies — the most commonly purchased supplement type — ranged from just in the first quarter, according to Nebraska-based consulting firm Telos Actuarial.

“While this is a small dataset across a select number of states, it’s an indication that carriers are looking to correct their premium rates in light of upward pressure on their claims experience,” said Brett Mushett, a consulting actuary with Telos.

Climbing Numbers

Premium rates vary based on the type of coverage chosen, where a beneficiary lives, and their age. For Plan G coverage, beneficiaries paid an in 2023, according to KFF. That amount has likely risen since.

“In some states, like Ohio, Medicare supplements for years would have a 3% to 5% year-over-year increase. Now it’s 10% to 15%,” said Amanda Brewton, owner of Medicare Answers Now, a marketing organization whose clients are sales agents.

In Alaska, Premera Blue Cross raised the premiums on its Plan G policies by nearly 12% for this year, according to rate sheets provided to Ñî¹óåú´«Ã½Ò•îl Health News by insurance agent Patricia Mack, who said another insurer raised rates by nearly 13%.

For example, a 65-year-old woman who last year would have been charged $172 a month for a Plan G policy would now face a monthly rate of $192, said Mack, who owns Alaska Insurance Benefits in Wasilla.

Premera spokesperson Courtney Wallace said in an email that Medicare makes changes to deductible and copayment rates each year, which affects supplemental plans that cover those increasing amounts.

Wallace also noted that the insurer saw higher medical service use among its members, “which further drove claims costs and ultimately impacted premiums.”

Agents and policy experts blame a range of factors for rising premiums: an increase in the use of medical services by beneficiaries; the aging of the population; increases in labor and medical costs; rules in some states governing Medigap plans; and people’s enrolling in — or getting out of — private Medicare Advantage plans.

“Five years ago, it was exceedingly uncommon to have a carrier with a rate increase of more than 10%. Now it’s very uncommon to see a rate increase below 10%, and it’s not uncommon to see it over 20%,” said Chalen Jackson, vice president for government affairs at Integrity, a Dallas-based company that sells life and health insurance.

Jaggi, who co-owns Jaggi Petry Insurance & Investments in Forsyth, Illinois, along with his daughter, said he eventually found other options for many of those 80-plus clients with the large increase, which came from an insurer that had previously been the lowest-cost option. But it wasn’t easy — and continuing increases are expected.

“These are unbelievable increases,” said Jaggi, who said he is seeing premium hikes exceeding 15% this year across a range of insurers.

Policy experts have outlined possible solutions, including for Congress to cap out-of-pocket costs for Medicare beneficiaries or subsidize the purchase of Medigap coverage.

“Traditional Medicare is the only federal health insurance program without an out-of-pocket cap,” Sen. Ron Wyden (D-Ore.) wrote in an email, adding that the program “needs to be updated and strengthened to protect the Medicare guarantee for American seniors.”

But making changes to Medicare that require congressional approval is unlikely in the current legislative environment, especially because adding an out-of-pocket cap would add costs to the federal budget.

How This Plays Out

People generally qualify for Medicare when they turn 65. Beneficiaries after they initially enroll in the traditional fee-for-service program to purchase a Medigap plan at standard rates without having to answer health-related questions.

Strict rules then kick in around when beneficiaries can enroll in or switch Medigap coverage and options become much more limited, with each one generally involving trade-offs or tough choices.

have what’s known as a “birthday rule,” which requires insurers once a year to allow people enrolled in a Medigap plan to change to different supplemental coverage — usually around their birthdays — without being medically underwritten. Those rules can help consumers, including those with health conditions, to switch.

An additional — Connecticut, Massachusetts, Maine, and New York — require insurers to offer at least one Medigap policy to all applicants either year-round or during an annual enrollment period, depending on the state. Changes are allowed no matter the person’s health.

Another option for those facing high Medigap costs is to leave traditional Medicare and enroll in a private-sector Medicare Advantage plan, which have out-of-pocket caps. But joining one means beneficiaries must generally rely on a set of in-network doctors and hospitals. And if they change their mind and want to go back to traditional Medicare, they have only a 12-month window in which to purchase a Medigap plan without passing health questions. After that, it can be more difficult.

“A lot of people don’t know that if they are in Medicare Advantage for a year, they can get turned down by a Medigap plan or charged really high premiums because of a preexisting condition, which for many people effectively traps them in MA plans,” said , a research associate at the liberal Center for American Progress and co-author of a on the issue.

There are some exceptions. For example, if a Medicare Advantage plan withdraws from a market or leaves the Medicare program, its enrollees can qualify for a supplemental plan without being asked health questions or charged more for having preexisting conditions.

For this year alone, about 2.6 million people when their insurer pulled out of their markets, according to KFF, and more than a million lost coverage for 2025. Many switched to other MA plans, but “somewhere around 440,000 of those people did go to a Medicare supplement policy,” sometimes because there was no other MA plan in their area, said George Dippel, president of Deft Research, a Minneapolis-based market research organization focused on insurance for older people. Deft is part of Integrity, the Dallas company.

Some Medicare experts note that anytime insurers enroll people whose health status they can’t consider — whether because of birthday rules or because their Medicare Advantage plan left the market and thus qualified them for an exemption from medical underwriting — it potentially exposes them to more health care utilization and higher costs, making them more likely to increase premiums across the board to offset the possible financial hit.

Another option mentioned by brokers for people looking to lower their costs is to consider one of the two types of Medigap plans that come with a deductible, which is currently just under $3,000 for a year. Those plans charge far lower monthly premiums than Medigap plans that pick up a much larger portion of annual amounts people must pay toward their Medicare services.

Still, “a lot of people are not comfortable with a $3,000 deductible,” Mack said.

This <a target="_blank" href="/medicare/medigap-medicare-advantage-premiums-rate-increase-few-alternatives/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

An elementary school teacher chose a low-price health insurance plan but soon realized she wasn’t clear about what it would mean for her family’s finances.

“Once I got the insurance card, I compared our old plan to our new plan, and that’s when I really got worried, because I didn’t really understand what a deductible was. It got me thinking, how do I use this insurance?”

— Madison Burgess, 31, of San Diego

When enhanced federal subsidies expired at the end of 2025, a lot of people buying their own health insurance on the state and federal exchanges saw their expected monthly rates jump. To keep costs down, many switched to a high-deductible health plan. These plans offer lower monthly payments, but in exchange patients can face steep out-of-pocket costs when they need care.

The plans are pretty common. In 2023, 30% of people who got insurance through their employer had a high-deductible plan, up from only 4% in 2006.

Madison Burgess, a teacher in San Diego, gets health insurance through her teaching job. But when she investigated adding her husband to her plan, it was just too expensive, so she started shopping on the exchange for a cheaper option for him.

The longer she scrolled through the plan options, the more overwhelming it felt. Insurance jargon made it hard to tell what her family would owe if her husband got sick.

“I didn’t know what a deductible was, so I just went with what was cheap, and now I have regret,” she said.

In exchange for that lower monthly premium payment, her husband’s coverage won’t kick in for most care until they’ve paid $5,800 in medical bills. Burgess didn’t know that the deductible must be met before insurance picks up part of the tab.

Deductible:

The amount you as the patient have to pay before insurance picks up part of the tab

Premium:

The monthly bill for your policy, paid to the insurance company

How do you prepare for thousands of dollars in upfront costs? One option is a health savings account, or HSA, which lets you save pretax money and is now available to people enrolled in lower-tier state and federal exchange plans, including bronze and catastrophic coverage. These plans generally have the lowest premiums on the exchange but the highest out-of-pocket costs when you need care.

Burgess had chosen a bronze plan and didn’t know HSAs were an option.

“I’ve never thought about having to put money away for a deductible,” she said.

Burgess and others are often more worried about socking away money for unexpected car and house repairs or vet bills.

If, like Burgess, you chose cheaper health coverage for this year only to discover you’re on the hook for meeting a high deductible, these tips can help you prepare.

1. You might qualify for an HSA and not know it.

If you’re enrolled in a bronze or catastrophic plan, you qualify to open a health savings account. Think of it as a medical piggy bank with tax perks. You put in pretax money, which lowers your taxable income. The money grows tax-free, and when you spend it on , those transactions are also tax-free. That’s what people call a “triple tax advantage.”

These accounts build a cushion for future health costs, such as doctor visits, prescriptions, and even products like over-the-counter medicine, tampons, and sunscreen.

The money typically can’t be used for monthly premiums, but the account is yours to use for qualified medical expenses for yourself, your spouse, or your dependents anytime in the future. The money in the account is yours, even if you change jobs or health plans.

An HSA is not the same as a flexible spending account, or FSA. FSAs are tax-advantaged too but are offered only through employers. The money expires annually and you lose any remaining money when you leave that job.

2. HSA-curious? Here’s how to open one.

You open a health savings account through a bank or other financial institution. The institution will issue you a debit card so you can make purchases from the HSA.

You can at any point during the year as long as you’re covered by an eligible plan. You can choose where to open the account, but be sure to check for any fees financial institutions charge and shop around.

If you get insurance through your job, your employer may require you to use a specific IRS-approved company.

Many people decide they can’t afford to contribute to an HSA. For some households, the desire to set aside money for medical expenses competes with the need to pay rent and buy groceries.

But there’s a detail that can make it feel more manageable. Contributions don’t have to be large. Just a few dollars a month can get you started.

There is, however, a limit. The IRS sets an annual cap on how much you’re allowed to contribute to an HSA. In 2026, an individual is limited to $4,400, or $8,750 for a family plan. Under that ceiling, the amount is up to you.

3. Preventive services should be covered at no cost to you.

All plans sold on marketplaces must cover at no cost to the patient as long as the care is provided in-network. Those services include routine immunizations and cancer screenings.

Beyond preventive care, understanding what different services cost can help you decide which type of medical appointment works best for your health needs and your wallet. For example, some plans charge less for a telehealth visit than to see your primary care doctor in person.

Check out your for more details.

4. Seek care early in the year.

Most deductibles reset on Jan. 1. Scheduling appointments or surgeries early in the year can be strategic if you discover a condition that requires ongoing care. If you can afford it, meeting your deductible sooner can make the rest of the year significantly cheaper, said Caitlin Donovan, a senior director at the Patient Advocate Foundation.

5. Consider paying cash instead of spending down your deductible.

Some hospitals, clinics, or other providers offer cheaper prices if you pay cash. You have the and explanation of how much a health service would cost if you paid out-of-pocket. Ask for the estimate before you get care. Then, compare that price with what your insurance company tells you it would cost if you used your insurance. If you decide to go with a cash payment, you’ll need to pay while you’re still at the doctor’s office, before charges get submitted to your insurance company.

Paying cash may save you money, but the amount you pay generally won’t count toward your deductible or out-of-pocket maximum.

“If you don’t think you’re ever going to hit your deductible — you’re that young invincible, and your deductible is $10,000 — negotiate the cash price,” Donovan said.

6. On an ACA plan? Update your income and use an HSA to avoid a tax surprise.

If you’re on an ACA plan and you’re eligible for subsidies, be aware: If your and you don’t update your marketplace application, you could owe thousands of dollars at tax time. The . Report raises, new jobs, or side gigs as they happen. If your income goes up, stashing money in an HSA can help because the money you put in the account doesn’t count toward your taxable income.

As soon as you report an increase in your income, that could mean higher premiums (if you no longer qualify for the same subsidy), but experts say it’s better to pay now than owe a big bill that you have to pay all at once.

“One of the biggest problems I see is someone is newly unemployed and they sign up for coverage, they say that they’re not making any money, and then eventually they get a job and don’t report it, and then they have this huge tax bill at the end,” Donovan said.

She advises updating your marketplace profile as soon as your income changes, which could newly qualify you for Medicaid or a plan that contributes more toward your medical bills.

Taylor Cook contributed to this report.

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and Ñî¹óåú´«Ã½Ò•îl Health News.

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“I call it the unaffordable care act,” he said. He reprised the line in his address, blaming “the crushing cost of health care” on Obamacare. 

Trump’s words play off an ongoing congressional debate that began late last year, ahead of the expiration of the enhanced tax subsidies that had lowered the cost of ACA insurance for millions of Americans. 

Democrats, looking toward the November midterm elections, continue to use that lapse to focus public attention on affordability. 

Republicans take a different view, routinely pointing to specific provisions as culprits. Among them, the law’s essential health benefits mandate, which says Obamacare plans must cover certain basic services — including emergency care, hospitalization, maternity care, and prescription drugs — without annual or lifetime dollar limits while enrolled. 

But my colleague Sarah Boden and I found that connecting EHBs to the premium increases consumers are feeling is not a straight line. 

For starters, it’s clear that ACA premiums have increased. 

An analysis by the right-leaning Paragon Health Institute shows that the average Obamacare premium for a 50-year-old since 2014. The average premium for employer-based plans grew 68% during the same period. 

Still, that’s not the whole picture.

Pre-ACA, coverage offered by employer plans was generally more generous and, therefore, costlier than coverage under individual market plans. Individual plans were cheaper also because they could bar applicants with health problems. Beginning in 2014, the ACA forced individual policies to look more like employer plans. As a result, premiums rose — sometimes faster than those of job-based plans. 

, however, were on the rise before the ACA took effect. 

An analysis by Jonathan Gruber at the Massachusetts Institute of Technology found that premiums grew by at least 10% a year from 2008 to 2010. 

So do EHBs raise premiums? In some ways, yes, compared with pre-ACA plans that might not have covered now-required services like maternity care or prescription drugs. 

But in other ways, EHBs can save money because they’ve increased access to preventive care, said , a professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health. 

Joseph Antos, a senior fellow emeritus at the conservative American Enterprise Institute, said other parts of the ACA — such as requiring insurers to accept anyone, regardless of health status, and limiting insurers’ ability to charge older people more — also played roles in boosting premiums. 

“It’s practically impossible to tease any one thing out,” Antos said.

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Still, 69% of those enrolled last year signed up again this year, often for less generous coverage. About 9% said they had to forgo insurance, according to the survey by KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

The KFF poll revisited the people who responded to of Affordable Care Act enrollees during open enrollment for ACA plans.

Steve Davis, a 64-year-old retired car salesman in Rogersville, Tennessee, who participated in both polls, said he was looking at an annual premium of about $14,000 to renew his ACA coverage this year. He didn’t qualify for enough of a tax credit to defray the cost, he said, after Congress gridlocked on an extension of more-generous subsidies put in place under President Joe Biden.

But things worked out for Davis. He landed a job at a convenience store that came with insurance, with his share costing about $100 more a month than the $300 he paid for an ACA plan last year, before the enhanced tax credits expired.

“As it happened, the Lord provided and my insurance kicked in through my employer,” he told Ñî¹óåú´«Ã½Ò•îl Health News.

In the November survey, many respondents were not sure what they would do for their health insurance in the coming year.

Some were waiting to see whether Congress would extend the enhanced premium subsidies, which had helped many people get lower-cost — or even zero-cost — health premiums.

Congress’ inaction left some consumers in a bind.

Now, the new poll found, affordability issues are hitting home as the midterm election approaches. And that might play a role in competitive districts, creating headwinds for Republicans.

Midterm Signals

Across all respondents who were registered to vote, the poll found more than half place “a lot” of blame for rising costs on Republicans in Congress (54%), with a similar share putting the same level of blame on President Donald Trump (53%). A smaller group placed a lot of the blame on congressional Democrats (34%). Among independents, a group expected to be a key factor in many districts, the percentages putting a lot of the blame on the GOP (56%) and Trump (58%) were higher.

Among Republicans, 60% placed a lot of the blame on Democrats in Congress.

“Those who have marketplace coverage, who remained on it, they’re really struggling with health care costs,” said Lunna Lopes, senior survey manager for KFF.

While more than half (55%) of returning ACA enrollees said they will have to pare back on other household expenses to cover health care costs, about 17% said they might not be able to continue paying insurance premiums throughout the year.

Overall, 80% of those who reenrolled for 2026 said their premiums, deductibles, or other costs are higher this year than last, with 51% saying they are “a lot higher.”

About three-quarters of ACA enrollees in the survey who were registered voters said the cost of health care will have an impact on their decision to vote — and on which party’s candidate they support.

Democrats were more than twice as likely as Republicans to say those costs will have a major impact on their decision.

“Democrats seem particularly more energized by health care costs than their Republican counterparts,” Lopes said.

Enrollment Tally Down

Data released Jan. 28 by federal officials showed that about 23 million people enrolled in Obamacare plans across the federal healthcare.gov marketplace and those run by states, about 1.2 million fewer than in 2025.

But it isn’t yet known how many are paying their monthly premiums on time, and many analysts expect overall enrollment numbers to fall as that data becomes available in the coming months.

For most people, having to pay more for premiums this year was mainly due to the expiration of the enhanced tax cuts, pollsters noted. Because the subsidies that remain are less generous, households have to pay more of their income toward coverage. Congressional inaction also meant the restoration of an income cap for subsidies at four times the poverty level, or $62,600 for an individual, sticking people like Davis with higher bills.

Not everyone saw increases.

Matthew Rutledge, a 32-year-old substitute teacher in Apple Valley, California, who participated in both KFF polls, said he qualified as low-income and his subsidies fully offset his monthly premium payment, just as they did last year. He does have copayments when he sees a doctor or accesses other medical care, but he told Ñî¹óåú´«Ã½Ò•îl Health News that “as long as the premium doesn’t go up, I’m fine with it.”

Rising premiums are fueled by a variety of factors, including hospital costs, doctors’ services, and the prices of drugs.

To lower premiums, insurers offer plans with higher deductibles or copayments. In the ACA, plans with lower premiums but higher deductibles are called “catastrophic” or “bronze” plans. “Silver” plans generally balance premiums and out-of-pocket spending, while the highest-premium plans with lower deductibles are “gold” or “platinum.”

About 28% of those who stayed in the ACA marketplaces switched plans, the pollsters noted.

One 56-year-old Texas man told pollsters that his family’s income exceeded the cap for subsidies, so they switched down from a gold plan to a bronze. “Even doing that, our premiums are three times what they were in 2025, with lower plan features and a higher deductible,” he said, according to a KFF poll news release.

For some, reenrolling was not a viable option.

In addition to the 9% who said they are now uninsured, about 5% said they switched to some type of non-ACA coverage.

Some people, like Davis, landed job-based coverage, while others found they qualified for Medicaid, the joint state-federal program for low-income residents.

Such churn in and out of ACA coverage is not unusual, Lopes noted. “People get a job. They get married. They age into Medicare,” the program for older or disabled people, she said.

The poll highlighted that many people dropping coverage were younger, between 18 and 29. About 14% of people in that range now say they are uninsured. 

That’s not surprising, given that younger people tend to use health coverage less. ACA insurers said one reason they raised premiums this year was because they expected more young or healthy people to drop out, leaving them with a higher share of older, more costly enrollees. Among those 50 or older, the poll found that only 7% are now uninsured.

GOP critics of the now-expired enhanced subsidies say they were always meant to be temporary. Extending them would have cost about $350 billion from 2026 to 2035, .

But not extending them means more people will become uninsured. The CBO said the extension would have meant 3.8 million more people having insurance coverage in 2035.

KFF pollsters, in February and early March, surveyed 1,117 U.S. adults, more than 80% of the ACA enrollees originally polled in November, online and by telephone. The margin of error is plus or minus four percentage points for the full sample.

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“I call it the unaffordable care act,” he said. He reprised the line in his address, blaming “the crushing cost of health care” on Obamacare.

Trump’s words also play off an ongoing congressional debate that began late last year with the expiration of the enhanced tax subsidies that had lowered the cost of ACA insurance for millions of Americans — and thrust the issue of ACA-related costs back to center stage.

Without those enhanced subsidies, the amount people pay toward monthly Obamacare premiums doubled, on average. The number of people enrolled in ACA coverage for this year has dropped by more than a million, and experts say more people could abandon coverage once premiums come due. Democrats are using this development to crank up the heat on Republicans ahead of the November elections and steer the conversation on the affordability issue.

Republicans fault the law itself for driving up these costs. For instance, Rep. Mike Lawler (R-N.Y.) that premiums “skyrocketed across the country since it took effect.”

Critics routinely point to several provisions within the ACA as the culprits — among them, essential health benefits, or EHBs. Under the law, Obamacare plans must cover certain essential services, including emergency care, hospitalization, maternity, and prescription drugs, without annual or lifetime dollar limits. But connecting EHBs to the premium increases felt by consumers is not straightforward.

Here’s a primer on key issues involved.

Checking the Numbers

It’s clear that Obamacare premiums have increased.

An analysis by the right-leaning Paragon Health Institute shows that the average premium for a 50-year-old with Obamacare since 2014. The average premium for employer-based plans grew 68% during that same time.

Paragon’s president, , told Ñî¹óåú´«Ã½Ò•îl Health News that this shows the ACA has made health care on the individual market more expensive.

Still, the comparison overlooks a couple of points. Pre-ACA, employer plans generally offered more generous coverage than individual market plans, so work-based coverage cost more. And individual plans were cheaper in part because they could bar applicants with health problems. Beginning in 2014, the ACA forced individual policies to look more like employer plans, covering a broader range of benefits and accepting both healthy and unhealthy applicants. As a result, premiums rose that first year. In the years that followed, ACA plans often experienced faster growth in premiums than job-based plans. Some policy analysts say this isn’t surprising because ACA plans started at a lower dollar base and had more room to rise.

States that saw less dramatic post-ACA premium increases, such as Massachusetts and New York, already mandated that individual-market plans provide EHB-like coverage, noted , a senior research fellow at the Heritage Foundation, a conservative think tank. These states also had higher premiums due to that and other provisions, such as not allowing plans to exclude people with preexisting conditions.

“It was a combination of things,” he said.

Blase acknowledges that the two types of insurance started at different price points. But he said the percentage change over time shows that the ACA faces “underlying inflationary pressures” — including the now-expired, more generous, covid pandemic-era subsidies — that affect its policyholders more so than employer plans.

Aside from that point, however, were on the rise even before the ACA took effect.

An analysis by Jonathan Gruber at the Massachusetts Institute of Technology found that between 2008 and 2010, premiums grew by at least 10% a year and were highly variable across states and insurers.

Consumers’ Other Costs

Over time, ACA deductibles — the amounts policyholders must satisfy in a given year before insurance kicks in — have seen large increases, with “bronze” plans now averaging $7,476 annually, up from $5,113 in 2014, according to KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. Bronze plans tend to have lower premiums than the other metal-level categories — “silver,” “gold,” and “platinum” — in part because of their higher deductibles.

The Trump administration is doubling down on high-deductible plans as part of its emphasis on affordability, making it easier this year for people age 30 and up to qualify for what are called “catastrophic plans.” These come with even larger deductibles than bronze plans.

The administration pitched a broad regulatory plan for 2027 to cement those changes, saying it was designed to lower premiums and expand choices. It would raise next year’s deductibles for catastrophic plans to $15,600 a year for an individual or around $30,000 for a family. It isn’t clear how popular such plans would be. Detailed enrollment figures for this year are not yet available, but estimates indicate only about 54,000 people chose catastrophic plans in 2025, and consumers can’t use federal subsidies to purchase them.

Before this Trump proposal, though, recent data showed that the rising rate of ACA plan deductibles had not outpaced deductibles for employer plans.

The weighted average — a calculation that gives more weight to ACA plans with the most people enrolled — shows in annual deductible amounts since 2014, from $1,881 to $2,912. During that same period, deductibles in plans offered by 59%, from $1,186 to $1,886, according to KFF’s annual employer survey.

Essential What?

To be clear, the ACA’s catastrophic and bronze plans must cover essential health benefits, as do all Obamacare plans. These EHBs fall into 10 categories of medical services and were included in the ACA to ensure individual policies meet a minimum standard of coverage and are comparable to employer-based health insurance.

Preventive services, such as annual checkups, vaccines, and certain cancer screenings, must be covered at no additional cost to patients. All plans must completely cover the cost of specific vaccines, including the annual flu shot. And insurers cannot refuse to pay for emergency care provided at an out-of-network hospital. Other EHBs are subject to out-of-pocket costs, such as copays at the doctor’s office or pharmacy counter.

In some ways, EHBs save money because they’ve increased access to preventive care, said , a professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health.

Services such as cancer screenings and lab tests can lead to earlier detection of serious conditions, when treatment is less costly, and positive outcomes are more likely.

“If you look down the list of essential health benefits, I think most people would reach the judgment that those are health care services that people should have access to,” said Larry Levitt, KFF’s executive vice president for health policy.

Joseph Antos, a senior fellow emeritus at the conservative American Enterprise Institute, said ACA requirements — such as requiring insurers to accept anyone, regardless of their health status, and limiting insurers’ ability to charge older people more for coverage — also have played roles in boosting premiums.

“Really, it’s practically impossible to tease any one thing out,” Antos said.

States do have latitude to add benefits that fall under the EHB umbrella. For example, bariatric surgery is covered as an EHB in , but not in . Pennsylvania’s EHBs also don’t include hearing aids, but do.

But the Trump administration’s 2027 regulatory proposal : When “states enact benefit mandates, plan premiums must generally increase to account for the additional coverage,” it reads. It also signals that added benefits can raise consumer costs and proposes that states be required to use their own funds to offset some of those costs.

Paragon’s Blase echoed this take in his bottom line. Mandating that plans cover EHBs without annual or lifetime caps, as required under the ACA law, encourages clinicians to overbill and overprescribe, he said. That drives up premiums and means a bigger check for insurers and medical providers at the expense of taxpayers. “You just turn patients into money factories,” he said.

, a senior research fellow at Georgetown University’s Center on Health Insurance Reforms, disagrees, saying that whatever EHBs’ role, they aren’t to blame for the year-over-year premium hikes.

People aren’t consuming medical care at exponential rates just because certain services are now covered: “Me not paying anything for that colonoscopy doesn’t make me want to get more of them,” she said.

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Jamie Estrada of Albuquerque, New Mexico, twice received injections of lidocaine in his upper spine to test if a permanent nerve ablation would treat his chronic neck pain. His pain vanished — until the numbing agent wore off about six hours later. The real zinger: His insurer was billed $28,000 for each 10-minute procedure.

Mark McCullick of Longmont, Colorado, was sent for a whole-body PET scan to find out whether his prostate cancer was back. The two-hour scan showed no evidence of cancer, but the $77,000 bill sent to the company that administered his insurance alarmed him.

Medical inflation has general inflation for years, with bills for many brief, routine procedures reaching tens of thousands of dollars.

These cases highlight the questions that haunt the American health system and the patients caught in its grip: What is a reasonable price for any health care visit or procedure, and how is it determined? How hard do insurers, the purported stewards of the patient’s hard-earned health dollars, fight to lower charges, and how closely do they scrutinize bills for accuracy?

Smith, Estrada, and McCullick’s cases are all “chargemaster” bills, calculated from the master price list that health providers place on services. Patients who have insurance don’t generally pay them. But they matter because they are often the starting point for the negotiated price the insurer agrees is reasonable to pay for the services. Patients are typically responsible for 10% to 20% of the negotiated price, their coinsurance — and when prices are this high, that can be a big number. What’s more, those negotiated rates are difficult for patients to access (until they get the bill) and seemingly arbitrary.

Also, because health insurers can offset high outlays one year by raising premiums and deductibles the next, they have little incentive to bargain hard for good deals for the patients they cover. So patients all pay unknowingly, indirectly.

In the cases of Smith and Estrada, their insurers paid the majority without questions. Penn State’s Hershey Medical Center, which treated Smith, received $61,000, or 62% of what it charged. New Mexico Surgery Center Orthopaedics, which treated Estrada, received $46,000, or 82%.

McCullick’s insurer, on the other hand, said it would pay Intermountain Health just 28% of his $77,000 bill. Then came another curveball: The hospital, which said it had gotten preauthorization, discovered after the fact that his scan was not covered. So it billed McCullick the full chargemaster rate of $77,000 — or, it offered, he could pay the cash rate of $14,259.

In an emailed statement, Chris Bond, a spokesperson for AHIP, the leading trade group for health insurers, blamed hospitals for the trouble, saying that plans are “focused on making benefits and coverage as affordable as possible for their members,” and that: “As the largest single category per premium dollar spent, increases in the cost of hospital-based care have an outsized impact on premiums.”

In a health system in which prices can vary exponentially with little transparency, how can patients afford to get sick?

‘It Makes No Sense’

Americans as a top priority for government in 2026, according to an Associated Press-NORC poll, expressing particular concern about cost, access, and insurance coverage.

The first Trump administration required insurers and hospitals to publish files containing cash, gross, and negotiated prices for various items and services. These raw, machine-readable price lists — often hundreds of pages filled with medical billing codes — to patient-customers.

Five years later, they’ve been ingested, parsed, and enriched by academics and startups, shedding light on the often-shocking disparities in prices and how they’ve come to exist.

“When we look at the data, whether it’s from a chargemaster or what insurers paid, it’s all over the map — it makes no sense,” said Marcus Dorstel, senior vice president of operations at Turquoise Health, a price transparency startup with payers and providers as clients. “The variation is huge, even in a specific area.”

When researchers at the Johns Hopkins Bloomberg School of Public Health looked at the data, they discovered that the price different insurers pay for the same billed charges “can be three or more times different at the same hospital,” said Ge Bai, a professor of health care accounting who was among the researchers.

The prices insurers pay are determined by numerous factors, including what’s in their contracts with health systems. Some health plans, such as Smith’s, automatically pay a percentage of the hospital’s billed charges, incentivizing hospitals to increase their rates. Hershey Medical Center increased its prices for 11 common hospital billing codes by an average of about 30% from 2023 to 2025, Dan Snow, a data scientist at Turquoise Health, calculated for this article. But those prices were not much different than those of other hospitals in Pennsylvania.

In other cases, an insurer might agree to pay a health system a case rate — a standard rate for a type of care, say a colonoscopy or an inpatient stay for pneumonia.

But there’s a lucrative catch, called a “carve-out,” which refers to a particular benefit that’s negotiated and paid separately. If the hospital used expensive drugs or devices, for instance, they can be billed in addition to the bundled case rate, with no limits on hospital markups. That was the case with McCullick’s PET scan; about 80% of the charge was not for the scan, but for a new kind of drug injected before the scan to detect cancer.

Most often the final prices depend on the relative negotiating power of the insurer and the health system: Which side has enough market sway to walk away if the other doesn’t meet its demands?

Such factors “can explain the price variations and patterns that we see,” Dorstel said. “In some markets insurers are price-makers, and in others they are price-takers.”

For Insurers, Paying More Is Profitable

Insurers aren’t incentivized to lower prices, because high prices mean they “get a slice of a bigger pie,” Bai said.

By law, insurers must spend 80% or 85% of premiums on patient care. But when prices rise, they can pass on the increase to customers in the form of higher premium costs and still meet their legal obligation. So higher premiums mean less money for the patient and more profit for the insurer.

For each spinal injection Estrada received, his insurance company’s contracted rate was $23,237.50. Estrada’s coinsurance was $5,166.20. With a high-deductible plan, he was asked to pay all of that more than $5,000 bill.

When he called to challenge the big bill, he said, the surgery center’s administrator told him the charges were the result of a “legacy contract” with the insurer that is “advantageous” and “favorable” to the center.

New Mexico Surgery Center Orthopaedics’ charges are many times those of the hospital where the center’s doctors admit patients, for example; there, Estrada’s insurance company’s contracted rate for the same spinal injection is just $2,058.67. And compared with the roughly $20,000 the insurer paid for each of Estrada’s injections, other insurers pay the center about $700 for the same procedure, Snow found.

The surgery center is part of a national group that owns more than 535 surgical facilities, United Surgical Partners International, which in turn is owned by Tenet Healthcare, a for-profit health conglomerate. That kind of market dominance can lend companies the negotiating power to charge — and get paid — what they want, Bai said.

The surgery center, United Surgical Partners International, and Tenet Healthcare did not reply to multiple requests for comment from Ñî¹óåú´«Ã½Ò•îl Health News.

With charges prenegotiated, insurers have little incentive to scrutinize questionable bills. When Smith asked for an itemized bill for her surgery, she discovered that she had been billed for two surgeries: one for the ectopic pregnancy removal and another because the surgeon noticed signs of endometriosis and performed a biopsy. Both were billed at the contracted rate of $37,923.

She was livid at the charges, which to her seemed like double-dipping. “That was one surgery,” she said. “There was one incision.”

A Yale University-trained lawyer, Smith consulted the federal Centers for Medicare & Medicaid Services’ , which note the two billing codes used for her surgery generally can’t be “billed together for the same patient encounter” because one more or less is bundled with the other.

Smith said she reached out to the Penn State hospital, the insurer, and even the state attorney general without resolution. So she expects she will, reluctantly, have to pay the $5,250 coinsurance that the hospital and insurer say she owes.

In response to questions from Ñî¹óåú´«Ã½Ò•îl Health News, Scott Gilbert, a spokesperson for the health system, did not respond to the specifics of this case, but wrote: “Penn State Health recognizes that health care billing can be confusing and often overwhelming for patients. The process involves many factors, including the type of care provided, where it’s delivered and the details of a patient’s insurance coverage.”

A ‘Reasonable’ Price?

After a reporter sent multiple inquiries to Intermountain Health, McCullick said an agent asked him what would be “a reasonable amount to resolve the situation.”

Sara Quale, a spokesperson for Good Samaritan Hospital, the Intermountain affiliate where he got the PET scan, wrote: “We sincerely regret the frustration this situation has caused Mr. McCullick,” noting that “we have been in consistent contact with him and will continue to follow up as needed.”

McCullick said he wants to pay his fair share but is still trying to figure out what that is — certainly less than the different self-pay prices he’s been offered, which all top $10,000. “The fluid nature of these numbers is mind blowing,” he wrote in an email.

As for Estrada, he was so angry that he decided not to go ahead with the nerve ablation. While he was being prepped for the procedure, Estrada recalled, the physician said he had “heard he might sue” and chastised him for being a troublemaker. The hospital did not respond to a request for comment on the allegations, and Estrada said he had never threatened legal action.

Estrada got off the table and put his shirt back on. “I’m not going to let this person put a big needle into my back.”

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She and her husband, Charles, a former high school teacher who goes by Chaz, planned to retire comfortably in the three-bedroom house where they raised their kids about 60 miles northwest of Sacramento.

But early last year, the 63-year-old became unsteady on her feet. One morning in May, she woke up with slurred speech and landed in the hospital, then rapidly lost the ability to move the right side of her body.

In August, as doctors continued to puzzle over a possible diagnosis, the couple received a notice saying that on Jan. 1 their combined health care premium payments through the state insurance exchange would shoot up from $540 a month to $3,899 a month. The reason: Federal enhanced premium subsidies expiring at the end of last year would no longer offset their payment.

They immediately canceled a monthlong cruise they’d been planning with friends and looked through their retirement accounts.

“Now, instead of thinking about where we can go in our retirement, we’re asking the question, ‘Are we still going to be able to stay where we are because of the health care costs?’” said Chaz, who retired in 2021 at age 59.

Then they received more bad news. In October, at the age of 63, Jean was diagnosed with ALS, a debilitating disease that will eventually leave her unable to speak, swallow, or breathe on her own. But Jean’s condition allowed her to enroll in Medicare, the federal health insurance program that covers adults 65 and older and people with disabilities. The diagnosis saved them roughly $1,600 a month in premiums — little comfort as Jean lost her ability to walk, bathe, and dress herself.

“It’s kind of morbid that, because of my diagnosis, I got put on Medicare right away, so at least we don’t have to pay that out-of-pocket,” Jean said, sitting in a wheelchair in her living room, a quilt draped over her legs to guard against the intense chills she now often gets. “We’re not going to get buried under this.”

Yet the premiums for Chaz’s plan and her Medicare remain a significant strain on their finances. The $2,300 a month they now owe, which includes roughly $342 in premium payments for Jean’s Medicare supplemental insurance, is higher than their monthly mortgage and eats up more than a quarter of their budget.

The Franklins are among the across the nation facing greater financial pressure after Congress chose not to extend 2021 enhanced federal subsidies. That assistance helped more than double enrollment in Obamacare plans to over 24 million.

The Congressional Budget Office estimated in 2024 that, without an extension of the tax credits, the number of uninsured Americans would climb by 2.2 million this year alone. , nationwide enrollment in ACA plans was down about 1.2 million year over year, though experts say it could be months before the full effects of rising premiums are known, as people miss payments and lose coverage.

The groups hit hardest will be , , and people living in high-cost states, said , a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. The Franklins are all three.

“They fell off what we call a subsidy cliff,” Pogue said. “It’s very, very shocking, the amount that a person would have to absorb.”

That’s because the expanded tax credits made the biggest difference for people nearing retirement age who sat just above thresholds, Pogue said. People such as the Franklins, who likely wouldn’t have qualified for financial help before expanded credits were implemented, are now losing that support at a time when insurers have responded to the uncertainty by dramatically raising rates.

Roughly half of people who were expected to lose eligibility for premium tax credits were ages 50 to 64, according to an , a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

A Retired Couple Faced a Huge Health Premium Increase. Her Terminal Diagnosis Saved Them Money.

Jean Franklin, 63, and Chaz Franklin, 64
Colusa, CaliforniaÌý

Chaz and JeanÌýFranklin thoughtÌýthey’dÌýsaved enough to retire comfortably. But when they found out the premium payment for their “silver” Affordable Care Act plan would soon rise from $540 a month to $3,899, they had to reevaluate. A couple of months later, Jean was diagnosed with ALS, a debilitating neurodegenerative illness that qualified her for Medicare. Her premium payment dropped to $342 a month. The couple still pays a combined $2,300 a month in premiums, more than a quarter of their budget. “It’s the terrible irony that because my wife got a disorder, I’m saving money, and a lot of it,” Chaz said.

Republicans who opposed the extension have said the premium assistance went directly to insurance companies rather than consumers, incentivizing fraud and wasteful coverage. They also say the enhanced subsidies, which had no upper income limit for eligibility, were far too generous in capping premium payments at 8.5% of income, no matter how much an enrollee made.

“Most Americans would agree that taxpayers should not be subsidizing the health insurance of someone making $250,000,” U.S. Rep. , a California Republican who an extension in January, wrote in an . “I cannot accept the simple extension of a program that will line the pockets of insurers and is riddled with fraud at the expense of the American taxpayer.”

Patient advocates say the premium increases and expiration of subsidies have forced people into difficult choices. “The young people who are healthy are the first to say, I’m going to roll the dice” and forgo coverage, said , executive vice president of policy and programs at the National Patient Advocate Foundation. “Those who are remaining in the system — because they have no choice — are holding off care, they’re holding off their meds, they’re going without necessary food.”

While the Franklins are getting by, they have relied on their sons to pay for a motorized recliner to assist with lifting Jean and a handicap van to transport her. Chaz, who broke a tooth a year ago, delayed fixing it because a crown would cost him $1,000.

This year, the couple will draw $36,000 more than they had anticipated from their retirement savings, most of it to cover Chaz’s insurance premiums.

“I have a nest egg,” Chaz said. “But there’s a lot of people around here who don’t.”

For a while, he was outraged.

“I wish Congress would get off their butts and solve this issue,” said Chaz, who is a registered Republican but blames both sides of the aisle. “You’re so busy bickering over stupid crap and it’s both parties pointing fingers and blaming. Where was this discussion two years ago?”

Now, Chaz said, he’s focused on making Jean, his wife of 27 years, as comfortable as possible.

Before she got sick, they did practically everything together — hiking, traveling, tai chi, amateur photography, and bug-hunting. One of her favorite specimens was the rain beetle, a fuzzy scarab-like insect that can’t feed as an adult, relying solely on fat stores from its larval stages.

In the mornings, Chaz and their sons, Charlie and Louis, take turns lifting Jean, dressing her, and helping her use the bathroom. It’ll be fodder for the counselor, she jokes to her sons, when they inevitably need therapy later in life.

Most days, Jean’s outdoor adventures rarely extend beyond being wheeled to her back patio, where she loves to watch their backyard chickens bobble around. Chaz’s stubbornness makes him a great patient advocate. Charlie always seems to know exactly when she needs a big hug, and Louis tells jokes that can still make her snort with laughter.

“I don’t know what I would do without my boys making me laugh,” she said.

In December, Chaz will turn 65, old enough to qualify for Medicare himself. “After this year — knock on wood — we should be OK,” Jean said, before pausing and shooting her husband a wry smile.

“Well, you’re gonna be OK.”

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This <a target="_blank" href="/health-care-costs/insurance-premium-payments-terminal-diagnosis-aca-subsidies-covered-california/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">