There’s a significant adjustment on the horizon in health care, and it could hit your pocketbook hard. On November 1st, when insurers release their premiums for enrollment in the Affordable Care Act (ACA) marketplace, many Americans will likely become ill with sticker shock. Some Americans will see prices double from what they were the previous year. Imagine you were getting ready to purchase Netflix and the price doubled—would you still get it? Or if the gas bill to warm your home doubled, would you go without? This is the dilemma facing approximately 24 million Americans in the coming months.
While much attention in and around health care has focused on pending Medicaid cuts, the more immediate crisis is the expiration of enhanced ACA tax credits on December 31, 2025. As a physician who studies healthcare finance policy, it’s crucial that I tell my colleagues in healthcare that not enough people – elected officials included — are discussing this major threat to our patients’ access to care.
Affordability Cliff
Drastic increases in health insurance premiums are expected in markets nationwide, with potential increases of 6-10% in the employer-based system and a median of 18% in ACA markets nationwide. If that was not jarring enough, losing the enhanced tax subsidies could lead to an additional increase in the ACA marketplace of more than 75% on average, with some locations & individuals seeing increases exceeding 500%. For many Americans, this will essentially double their premiums and force them to choose between healthcare coverage and necessities.
Consumer sentiment, an early economic indicator, continued to decline in September and is 21% lower than last year at this time. The Federal Reserve just cut interest rates, and other major financial indicators are showing economic strain. Americans are facing economic headwinds, and when faced with financial pressure, they prioritize essentials such as housing, food, utilities, transportation, and childcare. Health insurance premiums, especially those that are unaffordable, rank much lower. In health care, we’ve seen patients ration insulin during tough times—we will surely see patients go without insurance when their premium payments double overnight.
A Market That Has Been Working
Since enhanced subsidies came into effect in 2021, ACA marketplace enrollment has more than doubled from 11 million to 24.3 million in 2025. Between 2022 and 2024, enrollment increased 115% among those earning 250% of the Federal Poverty Level (FPL) or less—individuals making $33,975–$37,650. These are not Americans who can absorb massive premium increases. In 2023, the national uninsured rate fell below 8% for the first time since tracking began; this number will skyrocket if premiums increase as projected.
Fifty percent of marketplace enrollees work for small businesses, are self-employed, or are small business owners, and a majority of marketplace enrollees earn between 100% and 400% of the FPL. For these Americans, the marketplaces represent their only option for reasonable & comprehensive coverage—they cannot access affordable employer plans and do not qualify for government programs like Medicare or Medicaid.
More than fifty percent of ACA enrollees live in GOP districts & three out of 4 live in states won by Trump. However, those who are at risk for the highest premium increases live in blue states. This issue transcends partisan politics.
Taper (if we must)
Some would argue that these were implemented during COVID as temporary expansions. While true, these subsidies have had a drastic impact on people’s abilities to access coverage and care. An abrupt discontinuation during economic headwinds and other healthcare policy changes (as found in the One Big Beautiful Bill, for instance) is counterproductive. In medicine, we rarely suddenly discontinue a chronic medication that a patient has been on for years; instead, we taper to allow for adequate adjustment. If we want subsidies to remain temporary, we should phase them out gradually, giving hardworking Americans the dignity to adjust rather than forcing them to choose between healthcare and groceries.
The 24 million Americans enrolled in ACA marketplaces roughly equals the number taking Lipitor (Atorvastatin). Imagine changing overnight how millions access this medication. While consequences might not appear overnight, hundreds of thousands—if not millions—would suffer serious health consequences; a similar parallel holds.
Our Role as Healthcare Providers
My request is for you, fellow healthcare professionals, to follow this issue closely over the next couple of weeks and, if you have access to elected officials, let them know of your concerns. If the subsidies are not extended, prepare to help your patients understand why their coverage may become unaffordable.
As frontline providers, we are often tasked with defending a healthcare system that we have little ability to control directly. We should not bear the brunt of patient frustration when they can no longer afford to see their doctors. Instead, we should be prepared to point our patients toward the policy decisions that affected their access to care, so they can make informed choices about the politicians they elect to represent their health interests, regardless of political party.
The disruption is coming. The question is whether we will be prepared to help our patients navigate it—and whether we will use our voices to advocate for solutions before it is too late.