ACA Marketplace enrollees want coverage, but many to go without

Affordability is already a major challenge for people enrolled in plans through the Affordable Care Act's Marketplace. However, without an extension of enhanced premium tax credits, that challenge is about to worsen, prompting many enrollees to go uninsured.

A new report from KFF surveyed Marketplace enrollees at the start of open enrollment on Nov. 1, 2025. At that time, the federal government was shut down as lawmakers debated an extension of enhanced premium tax credits, which expanded federal subsidies to lower monthly health insurance premiums for Marketplace enrollees. The shutdown ended on Nov. 12 without a resolution on an extension.

The report found that affordability remains a top issue during the 2025 open enrollment period, with 56% of enrollees surveyed saying they have looked for, sought out or received information about the cost of their health insurance in 2026. Enrollees in states that use the federal Marketplace were more likely than their peers in states that run their own.

Marketplace enrollees are also generally aware of the debate surrounding enhanced premium tax credits. The majority of people had heard "a lot" or "some" about them (59%), while fewer than four in ten had heard "a little" or "nothing at all."

While premium costs are top of mind for enrollees, more than half anticipate (54%) a more significant increase in the cost of their Marketplace coverage next year. About one in four (26%) also expect a slight increase.

Of those expecting higher premium costs, those with higher incomes are somewhat more likely than those with lower household incomes to expect their costs to increase "a lot more than usual," KFF reported. This group is more likely to be affected by an expiration of the enhanced premium tax credits.

Overall, about 90% of Marketplace enrollees expect an expiration to have an impact on their monthly premiums next year, including seven in ten who anticipate a "major impact."

Higher costs could pose a challenge to Marketplace enrollment. While most enrollees represented in the survey believe health insurance is key to financial well-being, peace of mind and access to care, a quarter of respondents said they are very likely to go without health insurance if their monthly premium doubles.

Additionally, almost a third of respondents (32%) said they would be very likely to look for a different Marketplace plan with a cheaper premium, but high deductibles and co-pays. Another 15% said they would be very likely to search for a different job that provides health insurance that meets their needs.

Just 10% said they would be very likely to stay with their current insurance plan if their monthly premiums doubled.

Notably, enrollees in states with Republican governments were more likely to say they would go without insurance in light of higher costs. Enrollees in states that have not expanded Medicaid were also more likely to consider becoming uninsured.

In general, Marketplace enrollees believe Congress should extend the enhanced premium tax credits, with just 16% saying they should expire.

Payers and providers are preparing for a world in which enhanced premium tax credits expire. For providers, the expiration could mean up to $31.2 billion in revenue losses and another $7.7 billion in additional uncompensated care costs next year, according to the Urban Institute and the Robert Wood Johnson Foundation. Payers are also anticipating a shift in enrollment, which could mean a loss of younger, healthier beneficiaries.

"Premium tax credits will continue, but the removal of that threshold certainly has allowed people, particularly young people, to get access to plans. So, looking at people who typically are healthy and perhaps 26 years old, coming off of their parents' insurance," Lauren Lattany, director of government relations at AMGA, explained to RevCycle Management.

Payer risk pools are likely to worsen if this population moves plans or goes uninsured altogether. This could result in a double whammy for Marketplace enrollees if payers have to increase premiums again because of the shift in risk pools.

America's Health Insurance Plans (AHIP) urged Congress on Dec. 3 to prevent the expiration of the enhanced premium tax credits, while also implementing program integrity measures to prevent inappropriate enrollment in the Marketplaces.

"With open enrollment underway and 24 million Americans facing the largest-ever spike in health care costs in 2026, Congress should take bipartisan action to preserve the health care tax credits and further strengthen program integrity," AHIP said in the statement.

Congress continues to debate the next steps for the enhanced premium tax credits, although a couple of proposals aim to extend them for another three years. President Donald Trump had previously proposed a two-year extension with some changes to the credits, but has since abandoned the plan.

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.