At the turn of the new year, many people who get their insurance through the Affordable Care Act (ACA) Marketplace and use subsidies could see monthly premiums double or triple as ACA subsidies expire. Two experts at University of Maryland’s School of Public Health have been following developments closely.
Health policy advocate and assistant research scientist Dr. Francesca G. Weaks and health services researcher and assistant professor Dr. Mika Hamer help to clarify the wide-ranging implications.
1. Tens of millions to effectively lose access to care
As of 2025, 22 million people across the United States use ACA subsidies that make health insurance affordable. Unless Congress passes an extension, by January 1, 2026, anyone who received an ACA subsidy will see it disappear.
“ACA subsidies are issued on an income-based sliding scale and reduce the cost of health insurance premiums for people who buy health insurance through state-level ACA Marketplaces (or exchanges). These are people who do not qualify for Medicaid, don’t get insurance through their employer, and cannot afford to buy private insurance,” said Hamer.
In 2021, ACA subsidies were enhanced as part of the American Rescue Plan Act, largely in response to the COVID-19 pandemic, and further extended in the 2022 Inflation Reduction Act. The 2025 One Big Beautiful Bill Act does not extend the subsidies. The bill also disincentivizes Medicaid expansion and tightens eligibility for ACA subsidies, excluding refugees, asylum seekers, and people with temporary protected status.
“Newly uninsured people will effectively no longer have access to basic health care – they are stuck between not qualifying for Medicaid and not being able to pay higher insurance premiums,” said Weaks. “Improved life expectancy, lower child mortality, lower depression and higher feelings of well-being are all associated with universal health coverage. These subsidies were bringing us a little closer to universal coverage.”
The United States is the only high-income country in the world that doesn’t offer all citizens health coverage. Over 25 million people currently have no health insurance and without extending subsidies, it is predicted that another 4 million people could be uninsured by 2034.
2. Losing subsidies will affect everyone, hitting some groups harder
Though it’s easy to think the loss of ACA subsidies will only affect those using them, Hamer and Weaks say the impact will be broad and felt by almost everyone. People who will feel it most acutely are those who are already struggling to access quality affordable health care.
“People living in states that didn’t expand Medicaid, small business owners and their employees, older adults and rural Americans are among those who will see the greatest impact from subsidies expiring,” said Weaks.
“People whose premiums without the subsidy are higher will be the most affected. That will also include people living in high-cost areas where the cost of health insurance is greater,” said Hamer.
3. Costs will go up — for everyone
Hamer says longer-term effects will likely see everyone’s health care costs rising, no matter the source of their health insurance. ACA Marketplace insurers will raise premiums by about 26% on average in 2026 — on top of that, some people buying insurance in the Marketplace will see monthly premiums more than double.
Under the ACA, 41 states and Washington D.C. expanded Medicaid programs to include people with incomes up to 138% of the federal poverty level (for an individual in 2025, that’s $21,597). These programs may – or may not – have the means to absorb some of the people priced out of the Marketplace in 2026, but only when their income falls below the threshold. States that did not expand Medicaid under the ACA have already seen and will continue to see more people uninsured, said Hamer.
“As the proportion of the population without insurance grows, an increasing amount of care will be uncompensated, meaning hospitals, clinics and health systems have to increase prices for other payers – such as the commercially insured and Medicare members – to offset their losses or find ways to cut back on other expenses like workforce, technology or building maintenance,” said Hamer.
“This drives up cost across the healthcare ecosystem, raising premiums for everyone along the way.”
4. Health insurance marketplaces destabilized
Any insurance market needs a diverse risk pool to absorb unexpected high costs from some of the members, says Hamer.
“As prices increase, people who perceive themselves to be lowest-risk – young, healthy, less likely to need care – will exit the market. For them, the cost of insurance might not seem worth it,” said Hamer.
“The people who remain have the highest needs and highest costs. Over time, the high costs accrued by the insured population drive premiums up further, pricing out the lowest-risk people at every step. Without subsidies or other cost controls that keep insurance affordable, this spiral will eventually destabilize the market and lead to its demise.”
5. Poorer health and greater inequality
The old adage, prevention is the best medicine, is also proven by research. Uninsured people use preventative and primary care services less than those with insurance; Weaks says this was something that the ACA was seeking to change.
“The ACA made important preventative care services free for members – including blood pressure screenings, contraception, wellness visits, HPV vaccination, tobacco cessation counseling and colorectal cancer screenings. This allowed for early detection, treatment and prevention of health issues and improved long-term health outcomes,” said Weaks.
About a third of adults and 75% of uninsured people under 65 years old in the U.S. say they have postponed healthcare because of cost.
“People choose not to go to the doctor because they have to pay for the gas that will get them to work, and the income from that job isn’t enough for them to afford health insurance. These are not choices anyone should have to make,” said Weaks.
Hamer adds that such delays in care, especially for prevention and screening, lead to diagnosis of conditions when they are more difficult and more costly to treat.
“We will likely see progress from the last decade start to reverse, with more late-stage diagnoses of chronic diseases that can become terminal, as well as terminal illnesses that could have been caught earlier,” said Weaks.
“Health insurance without subsidies will limit upward socioeconomic mobility, perpetuate inequalities and increase reliance on public programs like Medicaid,” Hamer agreed.
6. Hospitals will feel the pain, especially in rural areas
Weaks notes that rural hospitals – already struggling financially – will be hit disproportionately hard when subsidies end in January.
“A third of all rural hospitals are currently in danger of closing because of rising healthcare costs, inflation and low reimbursement rates. This will definitely exacerbate existing challenges for low-income and rural communities who often must travel longer distances to seek out medical attention,” said Weaks.
For over 1,700 rural hospitals, patient revenues are estimated to decline by $1.6 billion if subsidies are left to expire.
“This will lead to greater financial burdens on hospitals that are already struggling,” added Hamer.
Final words
“Healthcare demand does not depend on whether or not we have health insurance. Everyone experiences accidents and injuries, worrying new symptoms, complications from chronic conditions and age-related health issues,” said Hamer. “And every one of us deserves treatment that won’t leave us bankrupt.”
“Why do we apply capitalist economic principles to determine who gets access to health care and who does not? Every person has a right to life and a right to care,” said Weaks. “Access to health care is a key factor contributing to a decent quality of life, thriving workforce and good health outcomes for society at large. It just makes sense.”