Costs, Coverage, and Enrollment Changes: Current Public Opinion and Policy on the ACA Marketplaces

Why It Matters

The surge in premiums and resulting coverage losses affect millions of Americans, shaping voter priorities and compelling policymakers to confront health‑care affordability ahead of the 2026 midterms.

Key Takeaways

• Premium subsidies expired, causing average 114% premium increase.
• 55% of enrollees cut food and basic expenses.
• Eight in ten report higher healthcare costs compared to last year.
• One in ten marketplace enrollees are now uninsured.
• Seventeen percent fear they cannot afford premiums for full year.

Summary

The KFF panel examined the fallout from the expiration of enhanced ACA premium subsidies, focusing on how rising costs are reshaping enrollment, coverage continuity, and household budgets. 2025 marketplace enrollees faced an average 114% premium hike, and sign‑up data show roughly 23 million people were enrolled or automatically renewed—about one million fewer than the prior year. However, many have not yet paid premiums, leaving actual coverage numbers uncertain.

A follow‑up survey of more than 1,300 original respondents (with 1,100 re‑interviewed) revealed that eight in ten now face higher health‑care expenses, half of whom cite sharply higher deductibles or co‑pays. Over half are cutting back on food and other essentials, and 55% say they are trimming basic household costs to afford health insurance. One‑in‑ten respondents have become uninsured, primarily citing the loss of subsidies, while 17% of those who remain on the marketplace doubt they can sustain premium payments through the year.

Respondents highlighted concrete trade‑offs: many switched from silver to bronze plans to lower monthly premiums, accepting higher out‑of‑pocket risk. Direct quotes underscore the strain—one participant noted, “Without the subsidy I simply cannot afford the premium,” and another explained moving to a lower‑metal tier “to keep the bill manageable.” The data also show health‑care costs now rank above food, utilities, and housing as voters’ top economic worry.

These trends are poised to re‑enter the political arena as midterm campaigns intensify, with health‑care affordability likely to dominate candidate messaging. Policymakers face pressure to address subsidy extensions or alternative relief, while insurers anticipate continued churn and potential increases in uninsured rates. The survey fills a critical data gap until official enrollment and uninsured statistics become available later in the year.

Original Description

Following the expiration of the enhanced premium tax credits at the end of 2025, many Americans enrolled in the ACA Marketplaces have faced higher health care costs and reconsidered their coverage options given affordability concerns, as shown in a new KFF survey. Eight in 10 say their health care costs are up, including half (51%) who say they are a lot higher. Among returning ACA enrollees, one in six say they are not confident they will be able to afford their premiums for the entire year, and most expect to cut back on basic household expenses. In addition, KFF found that one in 10 enrollees dropped their Marketplace coverage and are now uninsured, and three in 10 switched ACA plans.

During a virtual event, KFF public opinion and policy experts discussed key issues facing ACA Marketplace enrollees and policy considerations, particularly as health care cost and coverage issues rise to the top of voters’ concerns prior to the midterms.

Timestamps:

00:00 - Opening Remarks from Drew Altman

05:23 - Introduction by Larry Levitt

06:23 - Data on ACA Marketplace Enrollees by Cynthia Cox

11:14 - Survey of Marketplace Enrollees by Lunna Lopes

22:33 - Q&A