Earlier this year, Angelia Hoomes’s back pain was so severe that she couldn’t bend down to put a cookie sheet in the oven. She was hiring others to load and unload her dishwasher. Any time she wasn’t taking care of her now 2-year-old granddaughter, she was lying in bed, practically unable to move. Hoomes—who is deeply involved in progressive politics in her local community in Macon, Georgia—will even have to sacrifice her proud position as a poll clerk in an upcoming January special election.
Her pain has improved since she had her first back surgery in October. But when Hoomes started making plans to schedule her second surgery, she faced a new anxiety: She had to make sure that the procedure would occur before the end of December.
“They kind of squeezed me in on the last surgical day of the year for that particular doctor, because with everything up in the air, I was just terrified to let my surgical window go into the new year,” said Hoomes. The company that provides her health coverage is switching from a PPO to an HMO plan in the new year, and her doctor is no longer listed as being in-network.
But even with her surgery successfully scheduled, Hoomes still has fresh worries in the form of the sticker shock that she will face in 2026, when the amount she pays for health care will jump by more than $1,000. Hoomes obtains coverage through the Affordable Care Act marketplace. Thanks to enhanced government-sponsored tax credits, her monthly premium cost is currently 20 cents. But with those subsidies set to expire at the end of the year, Hoomes’s options will become considerably more expensive: She said that she could choose between a plan that costs around $1,100 per month or one that is $1,300. She will opt for the cheaper plan but will need to use her monthly Social Security payment—also around $1,100—to cover the cost.
“There won’t be much eating out in my future, I can say that, but it’s just going to have to come from somewhere. No vacations, no new clothes, no new shoes. Just make do with what I’ve got,” said Hoomes, who is also a type 2 diabetic. She has a vegetable garden that she is hoping will help supplement her diet, and plans to barter fresh produce to obtain eggs from a neighbor with chickens.
Hoomes is 63 years old, meaning that she is still two years away from being able to obtain health coverage from Medicare. She retired from her job as a retention specialist for Geico in 2022 due to her back and neck pain, and has relied on the ACA marketplace to obtain health care ever since. The marketplace is her only option: Hoomes said that she does not qualify for Medicaid, the federally subsidized health insurance for very low-income Americans, because of her existing financial assets, including an inheritance from her parents.
Enrollees close to retirement age like Hoomes will be particularly affected by the expiration, in part because insurers are already permitted to charge more for older people than younger ones, so the rising premium cost will come on top of already higher prices. Hoomes’s home state of Georgia is one of the states that saw enrollment in the ACA marketplace more than triple after the premium subsidies were instituted, meaning that it will be particularly affected by the higher health costs.
Hoomes is one of more than 20 million Americans who are enrolled in health care through the ACA marketplace. The Congressional Budget Office has estimated that more than four million people may lose coverage over the next decade if the subsidies expire. But the impact will extend beyond enrollees, affecting the American health care system as a whole.
“Writ large, we’re expecting to see a big reversal in the health insurance coverage gains that the U.S. has experienced in the past decade,” said Claire Heyison, senior policy analyst for health insurance and marketplace policy at the left-leaning Center on Budget and Policy Priorities. “Just focusing on the ACA marketplace, people in every state at every income range will be impacted by the premium increases if the premium tax credit enhancements expire.”
Extending the premium subsidies would have required action by Congress, but the issue became embroiled in political considerations. The 43-day government shutdown was spurred by congressional Democrats’ desire to force a vote extending the credits, a largely fruitless endeavor. Earlier in December, two competing partisan bills attempting to address the issue failed in the Senate. House Republicans passed a conservative health care bill last week without addressing the expiring credits. Four more centrist GOP representatives signed onto a discharge petition to circumvent House procedure and force a January vote on a Democrat-led proposal to extend the subsidies for three years—however, that measure is dead on arrival in the Senate.
The ACA limits the percentage of an enrollee’s income that they pay for health insurance premiums. The enhanced tax credits, first approved in 2021 and renewed in 2022, further lowered the share of income that already-eligible enrollees would pay in premiums. For people earning up to 150 percent of the federal poverty line in 2025, for example, the required contribution is $0. The expansion also made the credits newly available to households earning more than 400 percent of the poverty line for the first time.
According to analysis by health research organization KFF, premiums will more than double for enrollees if the enhanced subsidies expire, with an average increase in cost of 114 percent, from an average of $888 in 2025 to $1,904 in 2026. Recent KFF polling also found that 58 percent of enrollees believe they could not afford even a $300 increase in their health insurance payments, and 53 percent say it would be “very difficult” for them to find another source of insurance if their current coverage became unaffordable.
Functionally, the expiration of these premium tax credits will mean that low-income households lose access to free insurance altogether, and middle-income families will see their costs spike. The impact will be particularly significant for marketplace enrollees living in the 10 states that did not expand Medicaid under the Affordable Care Act. Forty states and the District of Columbia expanded Medicaid eligibility to nearly all adults with incomes up to 138 percent of the federal poverty line. But in those states where eligibility for Medicaid is still capped at 100 percent of the federal poverty line, those Americans living between 100 and 138 percent of the poverty level who might be reliant on the ACA marketplace right now could not only lose their coverage but also not be able to qualify for Medicaid. Around half of all current Marketplace enrollees have incomes between 100 and 150 percent of the poverty level.
But people living above 400 percent of the poverty line will also be deeply affected—particularly older enrollees and those living in higher-premium locations—as they will lose their credits entirely. Around half of those who would lose eligibility are between the ages of 50 and 64, according to KFF.
The dramatic increase in costs could lead people to either choose a plan with lower premiums—but which may have higher deductibles or out-of-pocket costs—or drop their coverage altogether. This could create a “death spiral” effect for health care coverage, said Liz Fowler, distinguished scholar at the Johns Hopkins Bloomberg School of Public Health, as healthier people drop their insurance.
“That trend over time—if nothing is adjusted and nothing is fixed—ends up undermining the stability of the risk pool each year. It gets a little bit worse and more and more expensive for those who want to stay in,” said Fowler.
Some people will have no choice but to continue paying for a far more expensive plan, even if their financial situation is uncertain. Tori Baggot, the owner of a small letterpress printing business in Pittsburgh, who is enrolled in health care through the ACA marketplace, needs to stay on her plan to help treat her chronic illness. Because she has a hypermobility spectrum disorder, which affects connective tissues in the body, Baggot requires a team of specialists for care.
“I’m choosing to take the bigger hit of the premium increase instead of changing my plan, because the specialists I have, I’ve been working with them for over a year now,” she said. “Just the idea of trying to find a new team of people, even if it would save me, like, I don’t know, $100, is crazy.”
Baggot currently pays $197 per month for health care. Beginning in January, her same plan will cost $365. Joining her husband’s health insurance through his job is not an option, she said, because it would cost more than what she pays through the marketplace. It also impedes her and her husband’s considerations about starting a family. Baggot is grateful that she has no employees; as a small-business owner, her biggest expense will soon be the cost of her own health care.
The expiration of the subsidies will also create significant uncertainty for enrollees who are currently unemployed. Jeremy Koulish, a software developer who lost his job as a contractor with the U.S. Census Bureau in May and is active in his local Working Families Party chapter, is currently job hunting; while he has “a few irons in the fire,” his future is far from concrete. Koulish, who lives in Modina, New York, is currently enrolled in health insurance through the ACA marketplace, but the cost of his current plan is set to jump from less than $400 a month to $1,600 a month. Because he has no income, he has now enrolled in Medicaid for next year while he seeks employment.
“I’ll take what I can get at this point, whether it’s three months, six months—unfortunately, I think that might get me off of Medicaid without offering me a great alternative, so I’m stuck with the $1,600 plan anyway, or just a much weaker plan with higher deductibles,” said Koulish.
The expiration of the enhanced credits comes within the larger context of dramatic cuts to Medicaid and changes to the ACA marketplace as part of massive Republican legislation that slashed government spending over the summer. The measure will tighten work requirements for Medicaid, and made several changes to the ACA marketplace, including shortening the open enrollment period and adding new verification requirements. (These provisions will go into effect in 2026 and 2027.) Between the changes to Medicaid and the ACA marketplace in the Republican law and the expiration of the premium subsidies, the number of uninsured Americans is expected to jump to 16 million by 2034.
Fowler believes that these changes are the latest salvo in a yearslong effort to undermine the ACA, even as previous efforts to repeal and replace the ACA were unsuccessful.
“I think it’s sort of part and parcel of a larger picture that’s all geared towards, ‘We didn’t like the ACA. We think we need to rethink health care. We don’t like many of the attributes and features of the ACA, but we don’t have a policy or a vision for what should be in its place,’” she said.
For his part, Koulish is worried about how the impending changes to Medicaid will affect him, particularly since he is only participating in the program “reluctantly.” “It’s really stressed me out. It introduces a lot of uncertainty in the near term, and I’m already losing a major lifeline,” he said, referring to the expiration of the ACA subsidies.
Heyison also noted that although ACA marketplace enrollees will be the most directly affected, the expiration of the enhanced subsidies will have an impact on the American health care system as a whole. Many insurers are already leaving high-risk areas, and may continue to pull out of states and counties as healthier people drop their coverage. Without health insurance, Heyison continued, emergency rooms and clinics might be overwhelmed by people who are postponing care.
“That could increase wait times at these clinics; that could increase wait times at emergency departments,” she said. “We should just expect health care to get harder to access for people as a result, not just people with ACA marketplace coverage but anyone—entire communities that use those clinics.”
For enrollees like Baggot, however, the most immediate concern is figuring out how to afford those extra expenses.
“The scariest part is I have no idea where the money is going to come from,” Baggot said.
