The Affordable Care Act’s (ACA) Marketplace has quietly become one of the federal government’s biggest success stories, providing health insurance to more than 24 million Americans in 2025 – a doubling since 2021.
But that success now stands on a knife’s edge.
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Unless Congress acts, enhanced premium tax credits that helped fuel this growth will expire at year-end.
The result? Higher premiums, fewer enrollees, and more uninsured Americans, especially among older, near-retirement households.
Millions of Americans could see the cost of their healthcare insurance increase if premium tax credits disappear.
Jeff Greenberg/Getty Images
Health insurance may disappear, and costs skyrocket
For millions, expanding advanced premium tax credits (APTCs) in 2021 was a game-changer.
By lowering out-of-pocket premiums through subsidies tied to income, the ACA became accessible to people who previously found it unaffordable. The Inflation Reduction Act extended these credits, but only temporarily.
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Under current rules, these credits are available to individuals and families earning up to 400% of the Federal Poverty Level (roughly $58,320 for an individual or $120,000 for a family of four in 2025).
However, absent Congressional reauthorization, the clock runs out this December.
The numbers are stark.
A new analysis from the Commonwealth Fund projects that 4 million people will lose coverage outright if the enhanced tax credits vanish.
Other proposed changes to marketplaces could further harm enrollment: an additional 4 million people could lose coverage by 2034 if the House-passed budget bill (H.R. 1) is enacted.
In Texas, over 1 million could become uninsured, with premiums up by $400+ annually.In California, 174,000 could lose coverage, facing $700+ hikes.In West Virginia, nearly every Marketplace enrollee — 98% — would see increases, with 16,000 losing coverage.
Older adults not yet eligible for Medicare are particularly vulnerable. Consider these examples from KFF:
A 40-year-old individual could see $1,000 more per year for the same coverage.A 60-year-old married couple could be looking at $20,000+ increases, depending on the state.
As Jae Oh, CFP, author of Maximize Your Medicare, explains: “Twenty thousand dollars does not matter what your net worth is. That’s a heck of a lot of money.”
Practical strategies for Americans losing health insurance
Oh emphasizes that individuals must now start budgeting for higher premiums, even if policy outcomes remain uncertain.
“Some people just stick with the same plan out of habit,” he notes, “but not at every price point. That needs to change.”
Related: Medicare recipients face a growing problem
Among his key recommendations:
Re-evaluate plan tiering: “If you’re in a gold plan, look at their silver plan. If you’re in a silver, look at a bronze plan.”Review COBRA carefully: While often seen as too costly, COBRA could become a better value if premium tax credits disappear. It offers continuity of care, retention of deductibles already met, and coverage for dependents, including adult children. “If your cost advantage dissipates, maybe COBRA was best all along.”Control income to manage subsidy eligibility: Strategies like Roth conversions, Roth contributions, and deferring income could help lower modified adjusted gross income (MAGI) and retain eligibility for reduced premiums. “Anything to defray or to try to limit your modified adjust gross income next year may be very valuable.”Plan around uncertainty: “We do not know at all what 2026 individual health insurance plans under the ACA look like. We will not know that until the very, very late fall this year.”
On the broader economic context, Oh adds: “That white-collar recession — anything that looks or sounds or feels like it — is real. People are on the bench, if you will, looking for employment.”
And for those relying on the ACA to maintain coverage between jobs: “This is that instance when the headlines will affect every aspect for those types of people… meaning that people who have accessed the APTC can be affected going into next year.”
A perfect storm: Expiring subsidies, Medicaid unwinding and budget cuts
Michael Gusmano, professor of health policy at Lehigh University, puts the risk into stark terms:
“The Commonwealth Fund’s analysis is depressing, but accurate and important. The temporary increase in subsidies that were adopted after the 2020 election had no chance of surviving if President Trump won re-election—and may have been difficult to extend even with Biden or Harris in the White House. Getting an extension of these subsidies through Congress would have been a challenge regardless of who is president.”
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He continues: “Beyond the expiration of the subsidies and loss of insurance through the ACA — and the millions who lost insurance coverage during Medicaid’s ‘great unwinding’ following the end of the public health emergency — the budget bill that was adopted by the U.S. House and is currently being debated in the U.S. Senate would increase the number of uninsured by several million more. Together, these policy changes would substantially erode health insurance coverage in the U.S. and move us in the direction of the situation in the U.S. before the full implementation of the ACA in 2014.”
The likely fallout?
“This will increase premature death, deteriorate public health, increase avoidable hospitalizations, and place enormous strain on the health care safety-net—including many rural hospitals that are already on the brink of disaster.”
Provider fallout and Medicaid’s safety net
Anne Montgomery, a health systems researcher focused on older adults, underscores the policy’s real-world harm:
“Not surprising to see the largest states would get hammered by these provisions. They are very harmful to individuals who won’t find it possible to buy private health insurance and who might, but for the massive Medicaid reductions in funding, wind up in Medicaid.”
“Millions will be stranded,” she said. “Dual eligibles will struggle to access Medicare if they fall through the cracks and don’t get Medicaid supplemental coverage help.”
“Then there is the fact that the health care system doesn’t operate for free — there are operations, services and wages to be paid,” Montgomery noted.” And there is no magic way that states have to replace the lost revenue, so many providers will stagger and increasingly fail.”
