In Their Own Words: Marketplace Enrollees Would Struggle to Afford Premium Hikes if Congress Refuses to Extend Improved Tax Credits

Olivia, a 22-year-old woman living in Michigan, is starting 2025 with a newfound sense of stability thanks to the health insurance that she buys through the Affordable Care Act (ACA) marketplace. In 2024 Olivia’s insurance covered her when she needed major surgery to relieve chronic pain. She was also able to access mental health treatment that kept her on track as she juggled multiple jobs in the gig economy and completed classes to become a certified nursing assistant. Being able to get the health care she needed has given her the energy and focus to pursue her personal and career goals.

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But Olivia’s health coverage is in danger. She is one of the more than 23 million people who buy their health insurance through the ACA marketplaces and will see their premiums skyrocket in 2026 if Congress does not act.

In 2021 Congress expanded the premium tax credit to make health coverage more affordable for people who buy marketplace insurance. But these improvements are set to expire at the end of 2025. If Congress refuses to extend these enhancements, almost all marketplace enrollees will see their insurance costs rise significantly. An estimated 2.2 million people will lose insurance in 2026 because they won’t be able to afford their health insurance, resulting in the largest single-year increase in uninsurance since the ACA was enacted. Black and Latino people will disproportionately lose coverage, which will increase existing racial disparities in health insurance coverage. 

But people of all identities will be affected. Olivia, who is white, says she would lose much of the progress she’s made in improving her health and her financial stability if the enhanced premium tax credit expires. “Finances have been very, very tight for me and my boyfriend this year. If the enhanced premium tax credit went away…we would both have to pick up side gigs on top of both our full-time jobs. I might have to go without my psych meds, which would not be ideal. I think my focus would be hindered. It would definitely be harmful for my life.”

“We’re Struggling Already As It Is”

In July, August, and September 2024, CBPP partnered with public opinion research firm PerryUndem to interview 15 marketplace enrollees in 11 states about the impact of the enhanced tax credits. Most interviewees said that they are already struggling with higher prices and that a spike in their health insurance costs would require difficult tradeoffs. “If it does happen, we’ll have to cut costs elsewhere and that's now digging into basic necessities, like, food, car, gas, rent. We're struggling already as it is,” shared Michael, a 54-year-old Asian ride-share driver in Arizona.

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Take Ximena, a 35-year-old Black woman living in Texas and working as an “as needed” and private duty nurse. She has ACA marketplace insurance for herself and her two young boys. Her health insurance premium will likely increase by more than $200 a month if Congress refuses to extend the enhanced premium tax credits. “That $200 currently is going to other things,” she said. “Gas is expensive, food is like exponentially expensive.”

If her increase ends up being closer to $400 a month, Ximena would drop her coverage, despite the anxiety it would cause. “If my family was uninsured right now, I would be so nervous,” she shared. “I don’t ever want us to be in a position where we need [insurance], and don't have it.” In other states, her kids might qualify for free or low-cost health insurance through Medicaid or the Children’s Health Insurance Program, but in Texas, their income is too high.

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“You Can Only Trim So Much”

To get ACA marketplace coverage, a person cannot have an offer of health insurance from an employer and cannot be eligible for other types of coverage, like Medicare or Medicaid. (People can qualify for marketplace coverage with an employer coverage offer if the lowest-cost health plan offered exceeds 9.02 percent of household income in 2025.)

If their marketplace premiums increase, most enrollees would need to either cut costs in another area of their life or drop their insurance.

Dropping health coverage isn’t an option for many people with chronic conditions. “If I didn't have health insurance I probably wouldn't be here,” said Erin, a 62-year-old white woman in Georgia who works part time as a mental health technician. Erin has been diagnosed with diabetes, heart failure, and arthritis, and sees doctors frequently to manage her conditions.

If Congress takes away the enhanced premium tax credit, Erin’s health insurance cost will likely increase by around $180 a month. Erin doesn’t know how she’d afford it. “I’d probably have to sit down and look at my budget and say, OK, where can I trim here, what other things do I need to do to save a little bit more money? But you can only do that for so much. I live a very frugal life to begin with.”

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Lisa, a 55-year-old white woman living in Ohio, also worries about how increased premiums would impact her finances, her health, and her children. Lisa has diabetes with multiple complications that limit her eyesight and mobility, making it difficult for her to find a job. If Congress lets the enhanced tax credits expire, her premiums would jump from around $100 a month ($1,200 annually) to $280 a month ($3,360 annually).

“I already feel like I have cut costs in every area of my life that I possibly can. I would have to look at everything in my life to determine what could be slashed even more,” she says. “And if I couldn’t do that, it's almost like I would have to just give up on trying to keep my health at a point where I can tell my kids that I would continue to do everything I could to be there for them…Right now, I am the only parent left in their lives. I want to be here for them as long as I possibly can.”

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Congress must act soon to make sure these tax credits continue so that millions of people can keep their health insurance in 2026. The consequences of failing to extend the tax credit improvements could be dire. People who go without insurance are more likely to delay or forgo health care, hold medical debt, and be hospitalized for avoidable health issues. As Ximena said: “I would want lawmakers to put themselves in that position before making any decisions that would affect not just me, but lots of Americans like me.”