Health insurance coverage under the Affordable Care Act (ACA) is declining as millions face rising premiums after the expiration of enhanced federal subsidies, according to data analyzed by KFF Health News. A North Carolina couple, Ross and Rebecca Tobiassen, canceled their ACA insurance in December after their monthly premiums jumped more than fourfold.
What Happened
The Tobiassens, small-business owners in western North Carolina, had relied on federally subsidized ACA plans since 2014. Their monthly premiums increased from $130 to over $550 after the enhanced tax credits created by the American Rescue Plan Act expired at the end of 2025. This increase forced them to drop coverage. The couple’s decision reflects a broader national trend, with ACA enrollment projections indicating a drop from over 22 million participants in 2025 to as low as 16.5 million in 2026.
Key Facts
- The expanded ACA subsidies, introduced during the COVID-19 pandemic under the American Rescue Plan, doubled ACA enrollment to about 24 million.
- North Carolina’s ACA individual marketplace enrollment fell 22% for 2026 compared to the prior year, a reduction of over 213,000 people.
- Nearly 100 clients from Pisgah Legal Services, a nonprofit helping low-income individuals with health insurance in North Carolina, chose to drop coverage during the most recent enrollment.
- Rising premiums and deductibles began increasing steadily in 2022 and spiked during the 2026 open enrollment period.
- Research from the University of Colorado Anschutz School of Medicine found bronze ACA plans are often unaffordable without subsidies.
Why It Matters
The loss of federal subsidies and rising premiums have made health insurance unaffordable for many who had previously relied on the ACA marketplace, increasing the percentage of uninsured Americans. This trend creates financial vulnerability, as uninsured individuals face risks of high medical costs without coverage. The erosion of the risk pool by healthier individuals dropping coverage may lead to further premium increases, creating a cycle difficult to reverse.
Background
The American Rescue Plan Act, passed during the COVID-19 pandemic, temporarily expanded tax credits that lowered ACA premiums nationwide, nearly doubling enrollment. Those federal subsidies were set to expire after 2025, causing premium hikes that reverse gains in coverage. Historically, insurance premiums and deductibles under the ACA have risen gradually since the program’s 2014 inception, with affordability continuing to be a persistent challenge for many families.
Analysis
Risha Gidwani, a healthcare policy researcher at the University of Colorado Anschutz School of Medicine, described the situation as a burden shift in affordability. Gidwani explained that as subsidies expire, many can no longer afford even the cheapest plans. She noted the “death spiral” effect whereby healthier individuals dropping out of insurance pools lead to higher premiums for sicker populations.
Who Is Affected
The changes have affected millions nationwide, with particularly steep enrollment declines in North Carolina. The Tobiassens represent small-business owners and families reliant on subsidized ACA plans. Other affected groups include part-time workers, gig economy drivers, artists, and individuals whose incomes disqualify them from Medicaid but prevent them from affording unsubsidized insurance.
What Remains Unclear
- Exact nationwide enrollment figures for 2026 have not yet been officially released by the Centers for Medicare & Medicaid Services.
- The long-term effects on premium rates and the overall risk pool are not yet quantifiable.
- Whether any legislative actions will reinstate or extend enhanced subsidies remains to be seen.
What Comes Next
The Centers for Medicare & Medicaid Services is expected to release comprehensive enrollment data soon. Meanwhile, no confirmed federal policy extensions or new subsidy programs have been announced to counteract the premium increases following the 2025 subsidy expiration.
Sources
This article is based on reporting and publicly available information from the following source:
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