Open enrollment for the Affordable Care Act begins Saturday, and this year's enrollment period is expected to largest increase in costs since the law came into force more than ten years ago.
More than 24 million Americans receive health insurance through the ACAalso known as Obamacare. The perfect storm will arrive in 2026 rising premiums and expiration of increased subsidies This has kept costs down for middle-class families, meaning many people will face higher bills or be forced to seek cheaper plans. As a result, some plan to remain uninsured.
“This is a high-risk situation for people,” said Stacy Dusetsina, a professor of health policy at Vanderbilt University in Nashville, Tennessee. “When it comes down to paying for food, electricity and heat versus health insurance that you don't know whether you'll need or not, it's hard to keep paying for it given how much of your budget it takes up today.”
Whether you're renewing your coverage or enrolling for the first time, here's what you need to know when open enrollment begins.
How long does ACA open enrollment last?
Open enrollment for ACA coverage runs from November 1 to January 15 in most states.
Some states have their own schedules. Idaho began the recruitment period on October 15th. and will close registration on December 15th. Massachusetts will continue registration until January 23, Virginia until January 30, and California, New York, Rhode Island and Washington, D.C. until January 31.
If you want your coverage to begin on January 1st, most states require you to enroll by December 15th. Plans selected after December 15th generally take effect on February 1st.
Until this year, people with lower incomes—up to about 150% of the federal poverty level, or about $23,500 per person—could sign up for ACA insurance at any time, not just during open enrollment. This option has now been exhausted.
The change took effect Aug. 25 after insurers expressed concern that some people were waiting until they were sick to sign up for coverage or later switching to a more generous plan that offered better coverage for their illness, said Cynthia Cox, director of the ACA program at KFF, a nonpartisan health policy research group.
The Trump administration also Ended ACA coverage for DACA recipientsalso known as “Dreamers”, for people who were brought to the United States illegally as children. Dreamers get the right to insurance during open enrollment in 2025but it was withdrawn in August after a rule change.
Why will premiums increase next year?
Two main factors are driving premiums higher next year: the expected expiration of expanded ACA subsidies and, to a lesser extent, higher insurer rates.
Expanded subsidies enacted in 2021 have helped millions of middle-class Americans pay less on monthly premiums. The issue is at the heart of the government shutdown, with Democrats saying they will not vote to reopen government unless tax benefits are provided.
At the same time, Insurers are raising rates for next year to keep up with rising hospital and prescription drug costs and growing demand for health care services.
A KFF analysis detected that insurers are raising premiums by an average of 30% in states that use HealthCare.govand an average of 17% in states that have their own marketplaces.
“The increase in premiums is the largest we have seen since the creation of the ACA exchanges,” said Gideon Lukens, senior fellow and director of research and data analysis in the health policy group at the Center on Budget and Policy Priorities, a nonpartisan research group. “At the same time, they are much less than the out-of-pocket increase due to expiring improvements.”
Coupled with the loss of enhanced subsidies, some people could pay an average of 114% more in premiums, Cox said.
“It’s a double whammy,” she said. “Not only are people losing tax benefits, but they are also paying for a dramatic increase in insurance company fees.”
Who is eligible for increased subsidies?
Before 2021, only people with incomes up to 400% of the federal poverty level were eligible for ACA subsidies.
expanded subsidies raised income limits on who is eligible to participate, expanding eligibility to many middle class people. People earning more than 400% of the federal poverty level — about $78,800 for an individual or $163,200 for a family of four — could get a tax break if their premiums exceeded about 8.5% of their income. Expanded tax breaks increased the amount of aid received.
“The reason we call them improvements is because they expanded eligibility and also increased credit for everyone,” Lukens said. “It really has resulted in incredible enrollment.”
About 22.3 million people — 9 in 10 ACA recipients — received the increased subsidies this year, according to government data.
Art Kaplan, director of medical ethics at NYU Grossman School of Medicine in New York City, said many people who got insurance through the ACA work or own small businesses.
“These are mom-and-pop stores,” he said.
What happens if the increased subsidies expire?
Congressional Budget Office Projects that an average of 3.8 million people will drop insurance and become uninsured each year over the next 8 years.
Those who keep coverage “will probably pay twice as much as they pay now,” Lukens said.
“We will return to a system in which there is a benefits cliff,” he added, “where a 60-year-old couple will no longer receive any help buying premiums and will have to pay the entire amount out of pocket.”
A 60-year-old couple earning $85,000 a year could pay about $2,000 more in premiums out of pocket, ranging from about $600 to about $2,600 a month, he said. A family of four earning about $130,000 could see their monthly premiums increase from $920 to $1,900.
Can you still get help paying for your insurance?
If the tax breaks expire, people with incomes less than four times the federal poverty level — about $62,600 for an individual or $128,600 for a family of four — would still be eligible for standard ACA subsidies, Cox said.
But the amount of aid they will receive will be significantly less, meaning they will also see higher premiums.
“They will still get the subsidy,” Cox said. “They’ll just get less financial help.”
Lukens said some low-income people who qualify for no-monthly premium plans under the expanded subsidies may lose that benefit, and there are concerns that many will drop coverage.
“There are estimates that approximately a million members in this lowest income group will likely remain uninsured if the improvements are not extended,” he said.
Others who no longer qualify for tax credits may find more affordable coverage by upgrading from a silver plan to a bronze plan, Cox said. Bronze plans typically have lower monthly premiums but higher deductibles, meaning you'll pay more out of pocket before the coverage kicks in.
Cox said to make sure your deductible is an amount you can realistically afford if you need care.
“What is included in the franchise?” she said. “Maybe there are preventive services, maybe there are doctor's visits or other things that are not part of the deductible. So read the fine print.”
Is it cheaper to give up health insurance completely?
Some people we are considering this option — put the money they would have spent on bonuses into savings.
Experts I warn you that this is a risky step. Paying cash can sometimes save money on smaller, more predictable expenses like x-rays or routine lab tests, but health insurance is designed to protect against unexpected and costly emergencies. A single hospital stay or surgery can cost tens or even hundreds of thousands of dollars out of pocket.
“This is what happens when people can't afford insurance,” said Dr. Adam Gaffney, a critical care physician and assistant professor at Harvard Medical School. “This is not a situation most people would want to be in.”
The clinics, known as federally qualified health centers, can offer low-cost primary care to uninsured patients, and some doctors can negotiate, although they often require payment upfront, said Michelle Johnson, executive director of the Tennessee Justice Center, a law firm and nonprofit advocacy group that helps people challenge medical bills.
Co-ops, also known as community self-insurance, can offer lower premiums and more flexibility, Kaplan said. However, they are often not regulated by the ACA and can leave participants on the hook for large medical bills, he said.
