Open enrollment for the Affordable Care Act (ACA) health insurance marketplace has officially begun for 2026, but this year comes with a mountain of challenges. With enhanced premium tax credits (ePTCs) set to expire and new federal restrictions taking effect, millions of people are facing steep premium increases that could erase more than a decade of progress expanding access to health care.
When the ACA was enacted in 2010, 46.7 million Americans – 15.4 percent of the population – were uninsured. That figure has dropped to just 8.2 percent today, largely because of the ACA’s success in providing affordable options for individuals and small businesses. ACA Marketplace enrollment surged to 24.3 million this year, more than double since 2020. Black and Hispanic enrollees saw the largest growth during this period, and women now make up more than half of all marketplace enrollees. For many women of color, women with middle to low incomes, and non-citizens, ACA coverage provides their only access to preventive services like mammograms, Pap tests, and prenatal care.
What’s Driving Coverage Loss?
Those historic gains are now at risk. The 2025 Budget Reconciliation Bill (H.R.1) cut nearly one trillion dollars from Medicaid and introduced new marketplace restrictions, leaving families with few affordable alternatives. A new final rule from the Trump Administration gives people less time to enroll, adds burdensome verification steps, and restricts eligibility for premium tax credits, all of which make it harder to stay covered.
The most immediate threat, however, is the pending expiration of the ePTCs – that H.R.1 failed to extend. These enhanced tax credits expand eligibility beyond 400 percent of the Federal Poverty Level (FPL) and reduce premiums for lower-income enrollees. Without them, an estimated 7.3 million people will lose ACA coverage in 2026 and over four million will become uninsured by the end of 2034.
Insurance companies have already set their 2026 rates assuming the ePTCs will expire. Many enrollees are seeing their premiums more than double when they check their renewal options this fall. For instance, a person earning $28,000 a year could see their annual premium jump from $325 to $1,562, according to KFF. Because over half of marketplace users are automatically re-enrolled, many may not realize the increase until their first bill arrives, when it’s too late to switch plans.
Who’s Most at Risk?
These shifts will hit historically marginalized communities hardest. H.R.1 eliminated PTC eligibility for most categories of lawfully present immigrants, including refugees, asylum recipients, survivors of domestic violence and many immigrants making below $15,650 a year, who also are barred from Medicaid due to immigration status. The new final rule further excludes Deferred Action for Childhood Arrivals (DACA) recipients from the definition of “lawfully present,” cutting off their ACA eligibility. Because of these policy changes, the Congressional Budget Office projects that 1.4 million immigrants will lose coverage by 2034.
Women of reproductive age are also acutely at risk. Some Republican lawmakers are using the fight over ePTCs as leverage in broader budget negotiations, while others seek to restrict abortion coverage in marketplace plans – even though federal funds are already prohibited from paying for those services under the Hyde Amendment. Such policies would only further disrupt coverage and compound barriers to care, particularly for women in states where abortion remains legal.
The impact of these changes will make care expensive for everyone. As healthier, lower-cost enrollees drop their plans, the marketplace risk pool will skew older and sicker, driving premiums even higher for those who remain. Meanwhile, funding for Navigator programs that provide enrollment assistance was slashed by 90 percent earlier this year, leaving fewer resources to help people understand their options or transition to Medicaid, if eligible.
A Call to Protect Affordable Coverage
After more than a decade of progress, the ACA marketplace stands at a crossroads. If Congress allows the enhanced premium tax credits to expire, the result will be higher costs, rising uninsured rates, and sicker women and families. Policymakers must act quickly to extend the ePTCs and stabilize premiums before open enrollment ends. Advocates and community organizations can help by ramping up outreach, assisting with plan comparisons, and ensuring that people understand their rights and options.
The success of the ACA was built on the promise that affordable coverage should not depend on income, ZIP code, or immigration status. Preserving that promise now requires decisive action. Congress has the opportunity, and an obligation, to ensure that everyone can afford their health coverage.
