Según el gobierno, el objetivo es ofrecer más opciones y primas más bajas.

Sin embargo, la iniciativa también contempla un fuerte aumento de algunos gastos de bolsillo anuales  —que podrían superar los $27.000 en un tipo de cobertura— y podrían hacer que casi 2 millones de personas pierdan su seguro médico.

Los cambios se producen en un momento en que el costo de la atención de salud es una preocupación clave para muchos estadounidenses: algunos están teniendo dificultades para pagar sus primas de ACA desde que los subsidios mejorados vencieran a finales del año pasado. Las cifras iniciales de inscripción para este año muestran una caída de más de un millón de personas.

La cobertura médica y su accesibilidad se han convertido en temas políticamente sensibles de cara a las elecciones de medio término de noviembre.

Los cambios propuestos por la administración Trump forman parte de una extensa norma que modifica distintos aspectos del sistema, incluidos los paquetes de beneficios, los gastos de bolsillo y las redes de proveedores de salud. Las aseguradoras usan estas reglas  como base para fijar las primas para el año siguiente.

Después de un período de comentarios públicos —en el que personas, organizaciones y distintos sectores pueden opinar sobre el proyecto— la norma se oficializará esta primavera.

La propuesta “pone a los pacientes, contribuyentes y estados en primer lugar al reducir costos y reforzar la rendición de cuentas sobre el dinero de los contribuyentes”, dijo Mehmet Oz, administrador de los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), en un comunicado de prensa del 9 de febrero.

Una de las formas en que lo haría es impulsando un tipo de cobertura —los planes catastróficos— que, según el propio documento, el año pasado atrajeron apenas a unos 20.000 asegurados, aunque otras estimaciones elevan esa cifra a cerca de 54.000.

“Para mí, esta propuesta indica que la administración ha encontrado su próximo gran objetivo en los planes catastróficos”, dijo Katie Keith, directora de la Iniciativa de Política de Salud y Derecho en el O’Neill Institute for National and Global Health Law del Georgetown University Law Center.

Estos planes tienen costos anuales de bolsillo muy altos para el asegurado, pero suelen ofrecer primas más bajas que otras opciones de ACA. Antes estaban limitados a personas menores de 30 años o a quienes enfrentaban ciertas dificultades económicas, pero el gobierno de Trump permitió que se inscribieran personas de más edad que perdieron la elegibilidad para subsidios para la cobertura de 2026. Aún no se sabe cuántas personas eligieron esta opción.

La norma consolida este cambio porque hace elegibles a quienes tengan ingresos por debajo del nivel de pobreza ($15.650 este año) y a quienes ganen más de dos veces y media esa suma siempre que hayan perdido el acceso a un subsidio de ACA que reducía sus gastos de bolsillo. El texto también señala que una persona que cumpla con estos criterios sería elegible en cualquier estado, un punto importante porque esta cobertura actualmente está disponible solo en 36 estados y en el Distrito de Columbia.

Además, la propuesta exigiría que el límite máximo de gastos de bolsillo en estos planes alcanzara $15.600 al año para una persona y $27.600 para una familia, escribió Keith esta semana en Health Affairs.

Actualmente, el tope de gastos de bolsillo para planes catastróficos es de $10.600 para una persona y $21.200 para cobertura familiar. Salvo la atención preventiva y tres consultas cubiertas con un médico de atención primaria, ese monto debe alcanzarse antes de que el resto de la cobertura entre en vigencia.

En el texto presentado, la administración afirma que los cambios propuestos ayudarían a diferenciar los planes catastróficos de los planes “Bronce”, el siguiente nivel, y posiblemente impulsarían una mayor inscripción en los primeros. Según el mismo documento, hoy esa diferencia no siempre es significativa cuando las primas son similares. Elevar el tope de gasto de bolsillo de los planes catastróficos a esos niveles, argumentan, serviría para establecer esa distinción.

“Cuando existe una diferencia tan clara, los consumidores más sanos —que suelen ser los candidatos ideales para inscribirse en planes catastróficos— se sienten más motivados a elegir uno de estos planes, en lugar de un plan Bronce”, señalan.

Sin embargo, como los subsidios de ACA no pueden usarse para pagar las primas de los planes catastróficos, es posible que esto desaliente a los posibles beneficiarios.

La inscripción en los planes Bronce, que actualmente tienen un deducible anual promedio de $7.500, se ha duplicado desde 2018 hasta alcanzar unos 5,4 millones de consumidores el año pasado. Este año es probable que la cifra sea mayor.

Los datos de inscripción en algunos estados muestran un desplazamiento hacia los planes Bronce, ya que los consumidores fueron dejando los planes “Plata”, “Oro” o “Platino”, que tienen primas más altas, tras el vencimiento de subsidios mejorados a finales de 2025.

La iniciativa del gobierno también permitiría que las aseguradoras ofrezcan planes Bronce con niveles de copagos y deducibles que superen lo que hoy permite ACA, pero solo si esa misma aseguradora también vende otros planes Bronce con niveles más bajos de costos compartidos.

En lo que describen como un enfoque “novedoso”, las nuevas regulaciones permitirían que las aseguradoras ofrezcan planes catastróficos multianuales, en los que las personas podrían permanecer inscritas hasta por 10 años. Durante ese período, los límites de gastos variarían. Por ejemplo, los costos podrían ser más altos en los primeros años y luego bajar a medida que el plan se mantenga vigente. La presentación solicita comentarios específicos sobre cómo podría estructurarse un plan de este tipo y qué efecto tendrían los planes multianuales en el mercado en general.

“Por lo que entendemos hasta ahora, las aseguradoras podrían ofrecer la póliza por un año o por períodos consecutivos de hasta 10 años”, explicó Zach Sherman, director gerente de política de cobertura y diseño de programas en HMA, también conocida como Health Management Associates, una firma de consultoría en políticas de salud que trabaja para estados y aseguradoras. “Pero aún estamos analizando los detalles de cómo funcionaría”, añadió.

Matthew Fiedler, investigador principal del Centro de Políticas de Salud de Brookings Institution, advirtió que el paquete regulatorio que propone el gobierno incluye muchas disposiciones que podrían “exponer a los inscritos a gastos de bolsillo mucho más altos”.

Además de los cambios previstos para los planes Bronce y catastróficos, Fiedler señaló otra disposición que permitiría vender en el mercado de ACA planes que no tengan redes fijas de proveedores de salud. Es decir, la aseguradora no habría firmado contratos con médicos ni hospitales específicos para aceptar su cobertura.

En su lugar, estos planes pagarían a los proveedores un monto fijo por sus servicios médicos. Podría ser una tarifa única o un porcentaje de lo que paga Medicare. La iniciativa establece que las aseguradoras tendrían que garantizar “acceso a una variedad de proveedores” dispuestos a aceptar esas sumas como pago total. Sin embargo, los asegurados podrían quedar expuestos a gastos inesperados si un médico o centro de salud no acepta esas condiciones y le cobra al paciente la diferencia.

Debido al amplio alcance de la norma —que incluye muchas otras disposiciones— se espera que reciba cientos, si no miles, de comentarios públicos hasta principios de marzo.

El corredor de seguros de Pennsylvania Joshua Brooker dijo que le gustaría que se exija a las aseguradoras que venden planes catastróficos con gastos de bolsillo muy altos que también ofrezcan otros planes catastróficos con límites anuales más bajos.

En términos generales, agregó, una mayor variedad de opciones podría resultar atractiva para personas en ambos extremos de la escala de ingresos.

Según explicó, algunos consumidores con mayores ingresos —especialmente quienes ya no califican para subsidios para las primas de ACA— preferirían pagar una prima más baja, como la que se espera en los planes catastróficos, y asumir de su propio bolsillo los gastos médicos hasta alcanzar ese tope máximo.

“Están más preocupados por un infarto que cueste medio millón de dólares”, reflexionó Brooker.

La situación es más difícil para quienes están por debajo de la línea de pobreza, no califican para subsidios de la ACA y, en 10 estados, muchas veces tampoco cumplen los requisitos para Medicaid, opinó. “En esos casos, es probable que se queden sin seguro médico”. Al menos un plan catastrófico, dijo, podría permitirles acceder a la atención preventiva y limitar un desastre financiero si terminan en un hospital. “A partir de ahí, incluso podrían calificar para programas de atención caritativa del hospital que ayuden a cubrir los gastos de bolsillo”, dijo.

En general, afirmó: “ofrecer más opciones en el mercado no perjudica, siempre que la propuesta se divulgue de manera adecuada y el consumidor la entienda”.

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While more Americans enrolled than some policy analysts had expected, the number was still 1.2 million below what it was at the same time last year. And experts say it will be months until the numbers are final. The timing will depend on how many of those people who signed up for coverage actually pay their premiums and remain enrolled. 

In coming weeks, “consumers may find they really can’t afford the premiums and cancel their plans, while carriers may also cancel coverage for nonpayment,” said Pat Kelly, executive director of Your Health Idaho, a state-based ACA marketplace, during a Jan. 22 call with reporters. 

The drop comes after several years of record-breaking enrollment, with 24.2 million sign-ups for the 2025 enrollment year. Enrollment growth took off after enhanced subsidies — which lowered the amount most households had to pay out of their own income toward premiums and removed an upper-income cap — went into effect during the Biden administration. Lawmakers, in adopting the enhanced subsidies, set an expiration date of Dec. 31, 2025. 

Congressional debate over extending those more generous subsidies was heated, even leading to the longest-ever government shutdown. Now, the subsidies are back to their original level, and people who earn more than four times the federal poverty rate (about $62,600 for an individual or $84,600 for a couple) can’t qualify for any at all. 

Falling enrollment was seen in most states this year, with the biggest drop in North Carolina, where sign-ups fell by nearly 22%, federal data shows. 

In a few places — including New Mexico, Texas, and Maryland, as well as the District of Columbia — the number of people selecting ACA plans increased. 

The jump was largest in New Mexico, with its tally of people selecting plans up by nearly 18%. Increases were in the single digits in the other states and Washington, D.C. 

New Mexico — uniquely — used its own tax dollars to fully offset the loss of the more generous federal tax subsidies for all consumers. A few other states, including California, Colorado, Maryland, and Washington, used state money to help some enrollees. 

We’ll keep watching to see how this unfolds over the coming weeks.

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The changes come as affordability is a key concern for many Americans, some of whom are struggling to pay their ACA premiums since enhanced subsidies expired at the end of last year. Initial enrollment numbers for this year fell by more than 1 million.

Health care coverage and affordability have become politically potent issues in the run-up to November’s midterm elections.

The proposed changes are part of a lengthy rule that addresses a broad swath of standards, including benefit packages, out-of-pocket costs, and health care provider networks. Insurers refer to these standards when setting premium rates for the coming year.

After a comment period, the rule will be finalized this spring.

It “puts patients, taxpayers, and states first by lowering costs and reinforcing accountability for taxpayer dollars,” said Centers for Medicare & Medicaid Services Administrator Mehmet Oz in a Feb. 9 press release.

One way it would do so focuses heavily on a type of coverage — catastrophic plans — that last year attracted only about 20,000 policyholders, according to the proposal, although other estimates put it closer to 54,000.

“To me, this proposal reads like the administration has found their next big thing in the catastrophic plans,” said Katie Keith, director of the Health Policy and the Law Initiative at the O’Neill Institute for National and Global Health Law at Georgetown University Law Center.

Such plans have very high annual out-of-pocket costs for the policyholder but often lower premiums than other ACA coverage options. Formerly restricted to those under age 30 or facing certain hardships, the Trump administration allowed older people who lost subsidy eligibility to enroll in them for this year. It is not yet known how many people chose to do so.

The payment rule cements this move by making eligible anyone whose income is below the poverty line ($15,650 for this year) and those earning more than 2.5 times that amount who lost access to an ACA subsidy that lowered their out-of-pocket costs. It also notes that a person meeting these standards would be eligible in any state — an important point because this coverage is currently available in only 36 states and the District of Columbia.

In addition, the proposal would require out-of-pocket maximums on such plans to hit $15,600 a year for an individual and $27,600 for a family, Keith wrote this week in Health Affairs. (The current out-of-pocket max for catastrophic plans is $10,600 for an individual plan and $21,200 for family coverage.) Not counting preventive care and three covered primary care doctor visits, that spending target must be met before a policy’s other coverage kicks in.

In the rule, the administration wrote that the proposed changes would help differentiate catastrophic from “bronze” plans, the next level up, and, possibly, spur more enrollment in the former. Currently, the proposal said, there may not be a significant difference if premiums are similar. Raising the out-of-pocket maximum for catastrophic plans to those levels would create that difference, the proposal said.

“When there is such a clear difference, the healthier consumers that are generally eligible and best suited to enroll in catastrophic plans are more motivated to select a catastrophic plan in lieu of a bronze plan,” the proposal noted.

However, ACA subsidies cannot be used toward catastrophic premiums, which could limit shoppers’ interest.

Enrollment in bronze plans, which currently have an average annual deductible of $7,500, has doubled since 2018 to about 5.4 million last year. This year, that number will likely be higher. Some states’ sign-up data indicates a shift toward bronze as consumers left higher-premium “silver,” “gold,” or “platinum” plans following the expiration of more generous subsidies at the end of last year.

The proposal also would allow insurers to offer bronze plans with cost-sharing rates that exceed what the ACA law currently allows, but only if that insurer also sells other bronze plans with lower cost-sharing levels.

In what it calls a “novel” approach, the proposal would allow insurers to offer multiyear catastrophic plans, in which people could stay enrolled for up to 10 years, and their out-of-pocket maximums would vary over that time. Costs might be higher, for example, in the early years, then fall the longer the policy is in place. The proposal specifically asks for comments on how such a plan could be structured and what effect multiyear plans might have on the overall market.

“As we understand it thus far, insurers could offer the policy for one year or for consecutive years, up to 10 years,” said Zach Sherman, managing director for coverage policy and program design at HMA, also known as Health Management Associates, a health policy consulting firm that does work for states and insurance plans. “But the details on how that would work, we are still unpacking.”

Matthew Fiedler, senior fellow with the Center on Health Policy at the Brookings Institution, said the proposed rule included a lot of provisions that could “expose enrollees to much higher out-of-pocket costs.”

In addition to the planned changes to bronze and catastrophic plans, he points to another provision that would allow plans to be sold on the ACA exchange that have no set health care provider networks. In other words, the insurer has not contracted with specific doctors and hospitals to accept their coverage. Instead, such plans would pay medical providers a set amount toward medical services, possibly a flat fee or a percentage of what Medicare pays, for example. The rule says insurers would need to ensure “access to a range of providers” willing to accept such amounts as payment in full. Policyholders might be on the hook for unexpected expenses, however, if a clinician or facility doesn’t agree and charges the patient the difference.

Because the rule is so sweeping — with many other parts — it is expected to draw hundreds, if not thousands, of comments between now and early March.

Pennsylvania insurance broker Joshua Brooker said one change he would like to see is requiring insurers that sell the very high out-of-pocket catastrophic plans to offer other catastrophic plans with lower annual maximums.

Overall, though, a wider range of options might appeal to people on both ends of the income scale, he said.

Some wealthier enrollees, especially those who no longer qualify for any ACA premium subsidies, would prefer a lower premium like those expected in catastrophic plans, and could just pay the bills up to that max, he said.

“They’re more worried about the half-million-dollar heart attack,” Brooker said. It’s tougher for people below the poverty level, who don’t qualify for ACA subsidies and, in 10 states, often don’t qualify for Medicaid. So they’re likely to go uninsured. At least a catastrophic plan, he said, might let them get some preventive care coverage and cap their exposure if they end up in a hospital. From there, they might qualify for charity care at the hospital to cover out-of-pocket costs.

Overall, “putting more options on the market doesn’t hurt, as long as it is disclosed properly and the consumer understands it,” he said.

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Todo esto es parte del complejo panorama durante el período de inscripción abierta de ACA para 2026. El debate en el Congreso sobre si extender los subsidios mejorados que se otorgaron durante la administración Biden provocó el cierre gubernamental más largo de la historia y centró la atención pública en el aumento de los costos de atención médica y en el problema de quién puede pagarlos.

Los subsidios mejorados, que redujeron el porcentaje del ingreso familiar que se debía pagar por la atención médica y eliminaron el límite de ingresos para calificar, expiraron a fines del año pasado. Como resultado, casi todas las personas que compran cobertura de ACA enfrentaron un aumento en los costos. Para algunos, las primas se duplicaron o incluso más, aunque aún se mantienen subsidios menos generosos.

Muchos expertos esperaban que la inscripción en ACA disminuyera este año, después de alcanzar un récord de 24 millones de inscritos en 2025.

“Si aumentas mucho el precio de algo, la economía nos dice que muchas personas comprarán menos o simplemente no lo comprarán”, dijo Katherine Hempstead, oficial de políticas de la Robert Wood Johnson Foundation.

Lo que hay que ver ahora:

Los números iniciales no son definitivos

La Oficina de Presupuesto del Congreso (CBO, por sus siglas en inglés) advirtió al Congreso en diciembre de 2024 que si no se renovaban los subsidios mejorados, 2,2 millones de personas perderían su seguro médico en 2026, y esa cifra aumentaría en los años siguientes. Analistas del Wakely Consulting Group también estimaron que millones optarían por no tener seguro este año.

Datos publicados el 28 de enero por funcionarios federales mostraron una disminución de aproximadamente 1.2 millones de inscripciones en comparación con el año anterior, tanto en el mercado federal de cuidadodesalud.gov como en los mercados manejados por los estados. En total, hubo 23 millones de personas inscritas, incluyendo 3.4 millones nuevas en la cobertura de ACA.

En la misma fecha del año pasado, había 24.2 millones de inscritos, con 3.9 millones de nuevos participantes.

Pero hay más detrás de esos números iniciales.

Por un lado, los datos de ambos años se basan en las inscripciones hasta el 15 de enero para el mercado federal, que cerró ese día su periodo de inscripción abierta. En cambio, los datos de los mercados estatales, en la mayoría de los casos, solo incluyen inscripciones hasta el 10 o el 11 de enero, aunque algunos permitieron inscripciones hasta fines de mes. Así que los números no reflejan lo que pudo haber pasado en esos últimos días. ¿Hubo un repunte en las inscripciones en los estados? ¿O, por el contrario, aumentaron las cancelaciones?

Además, los datos iniciales incluyen tanto a personas que se inscribieron por primera vez como a quienes ya tenían cobertura y fueron reinscritos automáticamente para 2026, lo cual plantea otras dudas.

En el caso de los asegurados que fueron reinscritos, los números reales no se conocerán hasta dentro de varias semanas o meses, cuando se sepa cuántos pagaron efectivamente sus primas. Algunos tal vez no prestaron atención a los costos de su reinscripción o esperaban que el Congreso extendiera los subsidios.

Ese es un factor importante a considerar porque las estimaciones de la CBO y de Wakely sobre cuántas personas perderían su seguro se basan en proyecciones de cobertura durante todo el año, no solo en las inscripciones iniciales.

En las próximas semanas, “algunos consumidores podrían darse cuenta de que realmente no pueden pagar las primas y cancelar sus planes, mientras que las aseguradoras también podrían cancelar coberturas por falta de pago”, dijo Pat Kelly, director ejecutivo de Your Health Idaho, el mercado estatal de ACA, durante una llamada con periodistas el 22 de enero.

Grandes diferencias entre los estados

También hay cambios importantes en los otros 19 estados (y el Distrito de Columbia) que administran sus propios mercados, algunos de los cuales han publicado datos más detallados sobre las inscripciones que el gobierno federal.

La mayoría de los estados registró una disminución en la inscripción para 2026 respecto al año anterior, siendo Carolina del Norte el que presentó la mayor caída, con una reducción del 22%, según datos federales.

En unos pocos estados —incluidos Nuevo México, Texas, California y Maryland—, además del Distrito de Columbia, aumentó el número de personas que eligieron planes de ACA.

El mayor incremento se dio en Nuevo México, con un aumento cercano al 14% en las personas que seleccionaron planes. En los otros estados y en Washington, D.C., los aumentos fueron de un solo dígito.

Nuevo México, de manera particular, usó fondos estatales para compensar por completo la pérdida de los subsidios federales mejorados para todos los consumidores. Otros estados, como California, Colorado, Maryland y Washington, usaron fondos estatales para ayudar a algunos inscritos.

La Red de Mercados Estatales (State Marketplace Network), un colectivo de 22 mercados estatales apoyado por la Academia Nacional de Políticas Estatales de Salud, dijo que las cifras iniciales de inscripción son preocupantes. Comparado con el mismo período del año anterior, las cancelaciones de planes aumentaron 83% en Colorado, las bajas se cuadruplicaron en Idaho y se duplicaron en Virginia.

Las nuevas inscripciones bajaron 32% en California respecto al mismo período del año pasado, según datos estatales. En Pennsylvania, personas de 55 a 64 años —el grupo con las primas más altas— y adultos jóvenes de 26 a 34 años están cancelando su cobertura en mayor proporción que otros grupos de edad, según datos del estado.

“Estamos viendo tasas mucho más altas de personas que abandonan su cobertura”, señaló Devon Trolley, director ejecutivo de la Autoridad del Intercambio de Seguros de Salud de Pennsylvania (Pennsylvania Health Insurance Exchange Authority). “En los últimos dos meses tuvimos 70.000 bajas, desde personas que se jubilaron anticipadamente hasta pequeños empresarios y agricultores que no saben cómo llegar a fin de mes”.

Algunos republicanos atribuyen esta disminución a medidas contra el fraude respaldadas por la administración Trump, que incluyeron cambios regulatorios y legislativos.

Aunque algunas de esas acciones fueron frenadas por un tribunal federal y no han entrado en vigencia, críticos de ACA —algunos de los cuales han publicado estimaciones controversiales sobre millones de personas que habrían sido inscritas de manera inapropiada— dicen que esas medidas explican la baja. Previamente habían culpado a los subsidios mejorados de fomentar inscripciones no autorizadas o cambios de plan motivados por comisiones de corredores de seguros.

No obstante, los estados que administran sus propios mercados de ACA informaron que había muy pocos o ningún caso de cambios no autorizados. A diferencia del mercado federal, las plataformas estatales aplican controles adicionales para evitar que los corredores accedan a la cobertura de los consumidores sin autorización.

Entre quienes no regresaron al mercado, la razón principal es el costo, dijo Mila Kofman, directora ejecutiva de la Autoridad del Intercambio de Beneficios de Salud de DC (DC Health Benefit Exchange Authority), que administra el mercado de ACA en el distrito.

“Cuando analizamos quiénes son estas personas, vemos que la mitad son pequeños empresarios”, dijo Kofman. “No se trata de personas que estén cometiendo fraude”.

Primas más bajas, deducibles más altos

En lugar de quedarse con la reinscripción automática, muchos asegurados en distintos estados optaron por cambiarse a planes “Bronce”, que tienen primas más bajas pero deducibles más altas que los planes Plata, Oro o Platino.

California reportó que el 73% de los miembros que renovaron y cambiaron de plan eligieron uno bronce, en comparación con solo el 27% en el mismo período del año pasado, según la Red de Mercados Estatales. En Maine, los planes Bronce ahora representan casi el 60% de todas las pólizas compradas.

“Las personas tienen que ver qué se ajusta a su presupuesto mensual y buscar primas más bajas”, dijo Stacey Pogue, investigadora sénior del Centro para Reformas del Seguro de Salud de la Universidad de Georgetown. “Algunos cruzan los dedos esperando no tener que usar el deducible”.

En promedio, los planes Bronce tienen un deducible anual de $7.500. Todos los planes de ACA están obligados a cubrir ciertos servicios preventivos —como algunas vacunas, pruebas de detección de cáncer y otros exámenes— sin copago ni deducible, pero la mayoría de los demás servicios se cubren solo después de cumplir con el deducible anual.

Los deducibles altos pueden hacer que algunos pacientes eviten buscar atención médica, señaló Hempstead.

“Tienen miedo de usar su cobertura”, dijo. “Pueden posponer algo hasta que se vuelve más grave”.

Agregó que los proveedores médicos, incluidos hospitales y doctores, se están preparando para un aumento de pacientes asegurados que no pueden pagar sus deducibles.

“Todos anticipan que los hospitales tendrán que dar más atención caritativa, lo cual afectará sus finanzas y podría obligarlos a despedir personal, cerrar o reducir servicios”, dijo.

¿Tienes dificultades para pagar tu seguro médico? ¿Has decidido renunciar a la cobertura? Haz clic aquí para contactar a KFF Health News y compartir tu historia.

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It’s all part of a drama that roiled the ACA’s 2026 open enrollment period. Congressional debate over whether to extend more generous subsidies made available under the Biden administration led to the longest-ever government shutdown and focused public attention on rising health care costs and the affordability issue.

The enhanced subsidies, which expanded eligibility both by lowering the percentage of household income people had to pay toward their care and removing an income cap, expired at the end of last year. As a result, just about everyone buying ACA coverage saw their costs increase. For some, what they paid toward premiums doubled or more, even though less generous subsidies remain in place.

Many experts expected ACA enrollment, which hit a record 24 million in 2025, to fall this time around.

“If you raise the price of something a whole lot, economics tell us that a lot of people will buy less of it or not buy at all,” said Katherine Hempstead, a senior policy officer with the Robert Wood Johnson Foundation.

Here are things to watch now:

Initial Numbers Aren’t Final

The Congressional Budget Office told lawmakers in December 2024 that not extending the enhanced subsidies would cause 2.2 million people to lose insurance in 2026, with further increases in following years. Analysts with the Wakely Consulting Group also estimated that millions would opt out of insurance for this year.

Data released Jan. 28 by federal officials showed a year-over-year drop of about 1.2 million enrollments across the federal healthcare.gov marketplace and those run by states. Overall, there were 23 million enrollees, including 3.4 million new to ACA coverage.

At about the same time last year, there were 24.2 million sign-ups, with 3.9 million new to the marketplaces.

But there’s more to it than those initial numbers.

For one thing, both years’ data was pegged to Jan. 15 for the federal marketplace, which closed its open enrollment period that day. But, the data for the states that run their own marketplaces included sign-ups in most cases only through Jan. 10 or 11, even though some held open enrollment until the end of the month. Thus, the numbers don’t reflect what might have happened in those last days. Was there a surge in state sign-ups? Or, conversely, did the marketplaces see more enrollees cancel their coverage?

Additionally, those initial numbers are a mix of newly minted ACA enrollees and existing customers, many of whom were auto-reenrolled for 2026 — which raises other issues.

For existing, reenrolled policyholders, the real figures won’t be known for weeks or months, when it becomes clear how many actually pay their premiums. Some consumers may not have focused on their reenrollment costs or may have hoped Congress would extend the subsidies.

That’s an important factor to keep in mind because the CBO and Wakely estimates of millions losing insurance were based on projections for full-year coverage, not initial sign-ups.

In the coming weeks, “consumers may find they really can’t afford the premiums and cancel their plans, while carriers may also cancel coverage for nonpayment,” said Pat Kelly, executive director of Your Health Idaho, a state-based ACA marketplace, during a Jan. 22 call with reporters.

Sharp Differences in State Enrollment Patterns

Changes are also afoot in the 19 other states (and the District of Columbia) that run their own exchanges, some of which have issued more detailed data about enrollment than the federal marketplace.

Most states saw lower enrollment for 2026 than the prior year, with the biggest drop in North Carolina, where sign-ups fell by nearly 22%, federal data shows.

In a few states — including New Mexico, Texas, California, and Maryland, as well as the District of Columbia — the number of people selecting ACA plans increased.

The jump was largest in New Mexico, with its initial number of people selecting plans up by nearly 14%. Increases were in the single digits in the other states and Washington, D.C.

New Mexico — uniquely — used its own tax dollars to fully offset the loss of the more generous federal tax subsidies for all consumers. A few other states, including California, Colorado, Maryland, and Washington, used state money to help some enrollees.

The State Marketplace Network, a collective of 22 state marketplaces supported by the National Academy for State Health Policy, said initial enrollment figures raise concern. Compared with the same time last year, outright plan cancellations are up 83% in Colorado, disenrollments are four times what they were in Idaho, and Virginia has seen cancellations double.

New enrollments are down 32% in California from the same period last year, according to data from the state. In Pennsylvania, people ages 55 to 64, the group with the highest premiums, and young people 26 to 34 are terminating their coverage in higher numbers than other age groups, state data shows.

“We have drastically higher rates of people dropping their coverage,” said Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority. “We had 70,000 drop in the last two months, from early retirees to small-business owners to farmers not knowing how to make ends meet.”

On Feb. 9, Pennsylvania released final numbers, showing enrollment dropped by about 2% from last year, although that figure masks some of the effects. The state says nearly 18% of enrollees dropped coverage altogether, with older and rural residents being the most likely to fall out.

Some Republicans credited Trump-administration-backed anti-fraud measures, which included a range of regulatory and legislative changes, for tightening the system. Although some of those actions were paused by a federal court and have not taken effect, those ACA critics, some of whom have produced controversial estimates that millions may have been improperly enrolled, say that’s behind the decline. They have previously blamed the more generous subsidies for unauthorized enrollments or ACA plan-switching by commission-seeking brokers.

States that run their own ACA marketplaces, however, reported little or no such unauthorized switching. Relative to the federal marketplace, the state-based ACA platforms employ additional safeguards to prevent brokers from accessing consumers’ coverage without authorization.

Among consumers not returning to the marketplace, the main reason is cost, said Mila Kofman, executive director of the DC Health Benefit Exchange Authority, which runs the district’s ACA marketplace.

“When we looked at who these folks are, half are small-business owners,” Kofman said. “They are not folks committing fraud.”

Lower Premiums, Higher Deductibles

Rather than sticking with automatic reenrollment, existing customers in many states shifted sharply into lower-priced “bronze” plans that come with higher deductibles than silver, gold, and platinum plans.

California saw 73% of renewing members who switched plans move to a bronze plan, up from 27% at the same time last year, the State Marketplace Network reported. In Maine, bronze enrollment now represents almost 60% of all plans purchased.

People are “looking at what works in their monthly budget, looking for that lower premium,” said Stacey Pogue, a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. “Some might be crossing their fingers that they won’t need to meet their deductible.”

On average, bronze plans have an annual deductible of $7,500. All ACA plans are required to cover certain preventive services — such as some vaccinations, cancer screenings, and other tests — without a copayment or deductible, but most everything else is covered only after an annual deductible is met.

High deductibles can lead some patients to avoid seeking medical care, Hempstead said.

“People are terrified to use their care,” she said. “They may delay something until it’s more serious.”

She added that medical providers, including hospitals and doctors, are bracing for an increase in the number of insured patients who can’t afford to pay their deductibles.

“Everyone is anticipating that hospitals will have to give out more charity care, which will hurt their bottom lines and might lead them to have to lay off people or close or reduce services,” she said.

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The story drew responses from readers facing large cost increases if these enhanced subsidies expire. They wrote about trying to find ways to squeeze hundreds of dollars a month out of family budgets, or even facing the possibility of going uninsured — and thus not being able to continue cancer or arthritis treatment. A few said they were waiting to see whether Congress would act, while others were enrolling but choosing less expensive plans with higher annual deductibles. 

Those cost increases could have serious political repercussions. 

According to a KFF poll released this month, about half of current enrollees who are registered to vote said that if their overall health care expenses — copays, deductibles, and premiums — increased by $1,000 next year, it would have a “major impact” on whether they vote in next year’s midterm elections or which party’s candidate they will support. 

As for enrollment, the Centers for Medicare & Medicaid Services on Dec. 5 released early figures showing 949,450 new sign-ups — people who did not have existing ACA coverage — across the federal and state marketplaces. That’s down a bit from approximately the same period last year, when there were 987,869 new enrollees. But CMS showed an increase in returning customers who had already selected a plan for next year, with the number up by more than 400,000 from the same time in 2024.  

Jessica Altman, executive director of California’s insurance marketplace, and Audrey Morse Gasteier, executive director of the exchange in Massachusetts, both said it’s too early to tell how final tallies will compare with 2025’s record 24 million sign-ups nationally.  

California reported a 33% drop in new enrollments through Dec. 6. And Altman said more people are opting for “bronze”-level plans, which have lower premium payments than most other ACA plans but higher deductibles. 

Both state exchange directors said they are hearing from scared consumers.  

“Our call centers are getting heartbreaking phone calls from people about how they can’t understand how they can possibly remain in coverage,” Gasteier said. 

If Congress does act, even in January, the states say they can update their websites to reflect changes, but those updates could take a week or two. In the meantime, people who sign up for coverage would pay their premiums based on the originally programmed information, which assumed the subsidies would expire at the end of the year.

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Concerned shoppers, wondering if there’s anything they can do, are consulting insurance brokers or talking to representatives at ACA marketplace call centers.

“We’re hearing from people with complex medical conditions who don’t think they can survive if they don’t have access to medical care,” said Audrey Morse Gasteier, executive director of the Massachusetts Health Connector, that state’s insurance marketplace.

And some are considering going outside the ACA to find more affordable options. But that requires caution.

Congress looks increasingly unlikely to extend the enhanced subsidies before the year’s end. Late Wednesday, the House passed a package of measures favored by conservatives that does not address the subsidies and is largely viewed as dead on arrival in the Senate. Earlier Wednesday, however, four GOP moderates joined with Democrats to sign a discharge petition to force a vote — likely in January — on a three-year extension. The Senate and President Donald Trump would also have to approve the measure, but if extended the subsidies could be applied retroactively.

Meanwhile, the deadline for choosing a health plan is quickly approaching. The official end of open enrollment is set for Jan. 15 for coverage starting Feb. 1. In most states, it’s already too late to enroll for coverage starting Jan. 1.

Here are five considerations in the decision-making process:

1. Short-Term Plans: ‘You Have To Be Healthy’

Some ACA shoppers might find themselves considering short-term insurance plans sold outside the government-run marketplaces — or steered toward the plans by insurance brokers. Be wary.

Short-term plans are just that: insurance originally designed as temporary coverage for situations like changing jobs or attending school. They can look a lot like traditional coverage, with deductibles, copayments, and participating networks of hospitals and doctors. Still, they are not ACA-compliant plans and are not available on the official ACA marketplaces.

They are often less expensive than ACA plans. But they cover less. For example, unlike ACA plans, they can impose annual and lifetime caps on benefits. The vast majority do not cover maternity care. Some might not cover prescription drugs.

Short-term plans require applicants to complete a medical questionnaire, and insurers can exclude coverage or cancel a policy retroactively for those with preexisting medical conditions. Also, depending on the terms of the particular plan, a person who develops a medical condition during the coverage period might not be accepted for renewal.

In addition, short-term plans are not required to cover care on the ACA’s checklist of essential benefits, such as preventive care, hospitalization, or emergency services.

The shortcomings of the plans, which critics say are sometimes marketed in misleading ways, have led Democrats to label them “junk insurance.” The Trump administration argues they’re suitable for some people and has sought to make them more widely available.

“We recommend it when it makes sense,” said Joshua Brooker, a Pennsylvania insurance broker. “But if you’re going to enroll in short-term coverage, you need to know which boxes are unchecked.”

“They’re not for everyone. You have to be healthy,” said Ronnell Nolan, the president and CEO of Health Agents of America, a trade group.

And they’re available in only 36 states, according to KFF, a health information nonprofit that includes KFF Health News. Some states, such as California, prohibit them. Others set tight restrictions.

2. Beware of Coverage That’s Not Comprehensive

There are other types of health coverage offered by sales brokers or other organizations.

One kind, called an indemnity plan, is meant to supplement a traditional health insurance plan by paying toward deductibles or copayments.

Those plans do not have to follow ACA coverage rules, either. Generally, they pay a fixed dollar amount — say a few hundred dollars a day — toward a hospital stay or a smaller amount for a doctor’s office visit. Typically those payments fall short of the full costs and the policyholder pays the rest. They generally also require consumers to fill out medical forms stating any preexisting conditions.

Another type, a faith-based sharing plan, pools money from members to cover their medical bills. The plans are not required to keep any specific amount of financial reserves and members are not guaranteed that the plans will pay their health expenses, according to the Commonwealth Fund, a foundation that supports health care research and improvements to the health system.

Sharing plans expanded beyond faith communities after the ACA was adopted. Like short-term plans, they cost less than ACA plans but also don’t have to follow ACA rules.

They are not considered insurance, and some have been accused of fraud by state regulators.

“Yes, it is cheaper, and yes, it does work for some people,” Nolan said. “But you need to understand what that plan does. It would be my last resort.”

3. Consider a ‘Bronze’ or ‘Catastrophic’ Plan, But Be Aware of Deductibles

For those wanting to stay with ACA plans, the lowest premiums are generally in the categories labeled “catastrophic” or “bronze.”

Jessica Altman, executive director of California’s ACA exchange, said her state has noticed an uptick in enrollments in bronze-level plans. They have lower premiums but high annual deductibles — the amount a customer must spend before most coverage kicks in. Deductibles for bronze plans average nearly $7,500 nationally, according to KFF.

Another option, new for 2026, is expanded eligibility for catastrophic plans, which used to be limited to people younger than age 30. As the name suggests, they’re intended for people who want health insurance just in case they suffer a catastrophic health condition, such as cancer or injuries from a car accident, and the plans can have deductibles as high as the ACA’s annual limit on out-of-pocket spending — $10,600 for an individual or $21,200 for a family.

But now people losing subsidies because of the expiration of the enhanced tax credits can also qualify for the plans. However, they may not be available in every region.

Lauren Jenkins, a broker in Oklahoma, said some of her clients earning less than $25,000 this year had qualified for very low-cost or free plans with the enhanced subsidies. Next year, though, their costs may rise to $100 or more per month for a “silver”-level plan, a step up from bronze.

So she is showing them bronze plans to bring down the monthly cost. “But they might have a $6,000, $7,000, or $10,000 deductible they now have to pay,” Jenkins said. “For people only making $25,000 a year, that would be detrimental.”

Both bronze and catastrophic plans are eligible to be linked with health savings accounts, which can be used to save money tax-free for medical expenses. They are more popular with higher-income households.

4. Another Plan May Have Lower Premiums

It can pay to shop around. Some people may be able to find a lower premium by shifting to a different plan, even one offered by the same insurer. There are also different levels of coverage, from bronze to “platinum,” where premiums also vary. Brooker said that in some locations “gold”-level plans are less expensive than silver, even though that seems counterintuitive. 

Also, some people who run their own businesses but have only one employee might qualify for a group plan rather than an individual policy. Sometimes those can be less expensive.

Not every state allows this, Nolan said. But, for example, Nolan said, she has a client whose only employee is his wife, so she’s going to see whether they can get a group plan at lower rates.

“That might work out for them,” she said.

ACA rates for small group plans (fewer than 50 employees) vary regionally and are not always less expensive than individual coverage, Brooker said.

“It’s pretty all over the board as to where the rates are better,” he said.

5. Other Rules of the Road

Insurance experts encourage people not to wait until the last minute to at least take preliminary steps. Shoppers can go onto the official federal or state marketplace website and fill out or update an application with required income and other information necessary to determine what the 2026 plan year holds for them.

For instance, even without congressional intervention, subsidies will not go away entirely. They will be smaller, though, and there is an upper income limit — a cutoff for households earning more than four times the poverty level, which comes to $62,600 for an individual and $84,600 for a couple for 2026.

When shopping, consumers should make sure they land on an official ACA website, because there are look-alikes that may not offer ACA-compliant plans. Healthcare.gov is the official federal site. From there, people can find websites serving the 20 states, along with the District of Columbia, that run their own ACA exchanges.

The government sites can also direct consumers to licensed brokers and other counselors who can help with an application.

And a reminder: Consumers also need to pay their first month’s premium for coverage to take effect.

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But this time there’s an extra complication. Though it’s the middle of open enrollment, lawmakers are still debating whether to extend the subsidies that have given consumers extra help paying their health insurance premiums in recent years.

The circumstances have led to deep consumer concerns about higher costs and fears of political fallout among some Republican lawmakers.

According to a KFF poll released in December, about half of current enrollees who are registered to vote said that if their overall health care expenses — copays, deductibles, and premiums — increased by $1,000 next year, it would have a “major impact” on whether they vote in next year’s midterm elections or which party’s candidate they support.

For those caught in the middle — including consumers and leaders of the 20 states, along with the District of Columbia, that run their own ACA marketplaces — the lack of action on Capitol Hill has led to uncertainty about what to do.

“Before I sign up, I will wait and see what happens,” said poll participant Daniela Perez, a 34-year-old education consultant in Chicago who says her current plan will increase to $1,200 a month from about $180 this year without an extension of the tax credits. “I’m not super hopeful. Seems like everything is in gridlock.”

In Washington, as part of the deal to end the recent government shutdown, a Senate vote was held Dec. 11 on a proposal to extend the subsidies. Another option, which was advanced by Republicans and included funding health savings accounts, was also considered. Neither reached the 60-vote mark necessary for passage.

On the House side, Speaker Mike Johnson plans to bring to the floor a narrow legislative package designed to “tackle the real drivers of health care costs.” It would include expanded access to association health plans and appropriations for cost-sharing reduction payments to stabilize the individual market and lower premiums. It would also increase transparency requirements for pharmacy benefit managers. Like the bill put forward by Republicans in the Senate it would not extend the ACA’s enhanced subsidies. Lawmakers are likely to vote on such an extension at some point.

In general, Democrats want to extend the life of the more generous subsidies, created in response to the covid pandemic. Those are set to expire at the end of the year. Republicans are split, with many balking at the cost of a straightforward extension, as well as the policy and political implications that might come with a vote to buttress Obamacare, which many have long viewed as public enemy No. 1.

And a few back various proposals that would extend the tax subsidies, fearing that failing to do so will result in political fallout in next year’s midterm elections.

The result is that differing policy positions are being advanced by lawmakers on both sides of the aisle and in both chambers of Congress.

The White House, though supportive of HSAs in principle, has not made clear its choice among the various Capitol Hill plans.

Meanwhile, the clock is ticking for shoppers. People needed to choose their ACA plan before Dec. 15 for coverage to begin Jan. 1. Open enrollment continues in most states until Jan. 15 for coverage beginning Feb. 1.

The marketplaces, too, must have contingency plans in case Congress intervenes. These adjustments could take days or weeks.

“We have a plan on the shelf” to go update the website, including notifying consumers of any changes, said Audrey Morse Gasteier, executive director of the Massachusetts Health Connector, a state-based ACA insurance marketplace.

Still, not many working days remain on Congress’ 2025 calendar, and “in many ways, it feels like they are farther apart than they were even a few months ago,” said Jessica Altman, executive director of Covered California, that state’s ACA marketplace.

Waiting for Numbers

Both Altman and Gasteier said it’s still too early to tell how final enrollment tallies will come out, but already there are indications of how sign-ups will compare with last year’s record high of about 24 million.

The Centers for Medicare & Medicaid Services on Dec. 5 released figures from about the first month of open enrollment, showing 949,450 new sign-ups — people who did not have ACA coverage this year — across the federal and state marketplaces. That’s down a bit from approximately the same period last year, when there were 987,869 new enrollees by early December.

Up slightly, however, are returning customers who have already selected a plan for next year. That stands at about 4.8 million, according to CMS, compared with about 4.4 million at this time last year.

That initial finding — lower new enrollments but quicker action by some already covered — may reflect that “people who come back early in the enrollment period are those who need the coverage because they have a chronic condition or need something done,” said Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms. “So they are more motivated in the front half.”

And the final number of federal marketplace enrollments takes time to shake out. “The rubber meets the road when people have to pay the first premium,” Corlette said. “With the federal marketplace, we won’t know that for some time.”

Some states have also released information from the first few weeks, with the caveat that many people may wait until mid-December or later to make coverage decisions. Affordability has emerged as a pressure point.

In Pennsylvania, for example, in the first six weeks of open enrollment there was a 16% decrease in people signing up for the first time compared with last year, according to data posted by Pennie, the state’s ACA insurance marketplace. For every one of those new enrollments, 1.5 existing customers canceled, Pennie reported.

There were some indicators that income is a factor: Most of those canceling earned 150% to 200% of the federal poverty level, or $23,475 to $31,300 for a single adult.

Most states automatically reenroll existing customers into the same or similar coverage for the following year. Letters and other notifications are sent to consumers, who then can let the coverage continue or go online during the open enrollment period to change their plan or cancel it.

California reported a 33% drop in new enrollments through Dec. 6. And Altman said she’s also seeing some other changes.

She said more people are opting for “bronze”-level plans, which have lower premium payments than “silver” or “gold” plans but also higher deductibles — the amount people have to pay before most insurance coverage kicks in.

Nationally, the average bronze-plan deductible will be $7,476 next year, while silver plans carry an average $5,304 deductible, according to KFF, a health information nonprofit that includes KFF Health News.

“That people are being forced to opt for plans with really high deductibles is a warning sign,” Altman said.

In Massachusetts, consumer calls to the state’s marketplace in the first month were up 7% over last year, Gasteier said.

Additionally, “our call centers are getting heartbreaking phone calls from people about how they can’t understand how they can possibly remain in coverage,” she said.

Detailing the Difference

If the enhanced tax credits expire, Obamacare subsidies will revert to pre-pandemic levels.

Households will pay a percentage of their income toward the premium, and a tax credit subsidy will cover the remainder, with the payment generally made directly to the insurer.

The enhanced subsidies reduced the amount of household income people had to pay toward their own coverage, with the lowest-income people paying nothing. Also, there was no upper limit on income to qualify — a particular point of criticism from Republicans. Still, in reality, some high earners don’t get a subsidy, because their premiums without it are less than what they are required to contribute.

Next year, without the more generous subsidies, those in the lowest income brackets will pay at least 2.1% of their household income toward their premiums, with the highest earners paying nearly 10%. No subsidies would be available for people earning more than four times the federal poverty level, which comes to $62,600 for an individual or $84,600 for a couple.

For those now shopping for coverage, that cap means a sharp increase in coverage costs. Not only have insurers raised premiums, but now that group’s subsidies have been cut entirely.

“They said, based on our salary, we don’t qualify,” said Debra Nweke, who, at 64, is retired, while her husband, 62, still works. They live in Southern California and are looking at coverage going from $1,000 a month this year to $2,400 monthly next year if they stay in the same ACA plan. “How can you have health insurance that is more than your rent?”

Senate Majority Leader John Thune said in early December that Republicans want to find a solution that will lower health care costs, but not one with “people who are making unlimited amounts of money being able to qualify for government subsidies.” He also objected to granting free coverage to those at the lower end of the income scale.

Even those getting subsidies say they are feeling the pinch.

“Our prices are going up, but even at that, I don’t have any other options,” said Andrew Schwarz, a 38-year-old preacher in Bowie, Texas, who gets ACA coverage for himself and his wife. His three children are on a state health insurance program because the family qualifies as low-income. Both Schwarz and Nweke took part in the KFF poll.

Schwarz’s coverage is going from $40 a month this year to $150 monthly next year, partly because he chose a plan with a lower deductible than some of the other options.

Schwarz said that while the health system overall has many problems, Obamacare has worked out for his family. They’ll just have to take the additional cost out of somewhere else in the family budget, he said.

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“What Democrats did 15 years ago was they radically changed all health care in America. They moved all physicians under hospitals. They changed all the reimbursement programs. They shifted everything in,” Lankford said Nov. 9.

This is one of a collection of Republican talking points related to the ACA that’s been regularly reprised, and there’s a reason for it.

Democrats have been promised a Senate vote this month on whether to extend the ACA’s enhanced subsidies, set to expire at year’s end. The debate, however, has given Republicans an opportunity to resurface old criticisms and reignite efforts to overhaul or even undo the ACA. One GOP argument is that the sweeping health law fueled industry consolidation, which has led to higher prices and pushed more doctors to sell their practices to hospitals or insurers.

But industry experts disagree about how much this market trend can be tied to the law known as Obamacare.

Like everything in health policy, it’s complicated.

“Most of us live in a different reality,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which supports extending the enhanced tax credits. “Our health system has many challenges, and I can’t say the cost to individuals, to taxpayers, is not an issue. But to say having better coverage for more people made all these problems worse is really a stretch.”

What’s Happened to Doctors and Hospitals?

First, some context. The ACA was passed by Congress in 2010, and most of its major provisions became effective in 2014.

Many health care mergers took place both before and after Obamacare became law, so it’s hard to quantify its effect.

From 1998 to 2017 — a nearly two-decade period that included the first three years of full ACA implementation — 1,573 hospital mergers took place. An additional 428 hospital and health system mergers were announced from 2018 to 2023, according to a 2024 brief by KFF, a health information nonprofit that includes KFF Health News.

“The consolidation trend was in place before the ACA and just continued” as hospitals and other entities sought to improve their negotiating power, said Glenn Melnick, who studies hospital economics and is a professor at the University of Southern California’s Price School of Public Policy.

The KFF brief did not directly address what role the ACA might have played in such mergers, although others have suggested its focus on coordinating care may have led to some of the activity.

Hospital groups contend that mergers are needed to bolster finances and counter increasing insurer consolidation, and that they can result in cost savings. Others disagree, arguing that many studies show price increases following mergers.

Even with that trend — and despite what Lankford said — not all doctors now work for hospitals.

The percentage of physicians who have sold their practices to hospitals or private equity groups continues to rise, with only 42% currently working in private practices, according to the American Medical Association. That’s down from about 60% in 2012, before the ACA’s main provisions took effect.

Those who sold practices during the past 10 years, according to the AMA, most often cited inadequate payment rates as the reason.

Others note that many doctors want to be part of a larger group, with more scheduling flexibility and fewer paperwork hassles. Other changes, including the 2009 law known as the HITECH Act, which required hospitals and doctors to boost their use of electronic medical records, added to physicians’ desire to sell, Kahn said.

“Physicians today, with their heavy debt load, are not looking to go into the old individual practice anymore,” Kahn said. “That didn’t happen because of the ACA.”

Another key dynamic driving this market trend is market leverage, which was happening anyway, say some policy experts.

Hospitals “got control of the physician groups for contracting purposes,” Melnick said.

When hospitals meet to negotiate with insurers, “they’ll say, ‘We’ll drop out of your network, and we control 30% of the doctors, so they’ll drop out, too.’ It was a leverage play, and it worked,” Melnick said.

How Do Insurers Fit In?

Like hospitals, some insurers have been on a buying spree, snapping up doctor practices, for example. Optum, a division of UnitedHealth Group, owns or is affiliated with nearly 10% of the nation’s physicians.

The health law “triggered an arms race among insurers and hospitals to grow larger and more expensive, leaving patients and small businesses with rising premiums and shrinking options,” said Joel White, president of the Council for Affordable Health Coverage, in testimony before a Senate subcommittee in November. The council touts among its priorities right-leaning issues such as opposing government-run health care and supporting expanded market competition and health savings accounts.

Again, the insurance question is complex.

The number of insurers filing annual reports with the National Association of Insurance Commissioners has fluctuated: for example, 949 in 2015 and 1,155 last year.

But aggregate numbers are only one measure. Several big insurers control large market shares. In one recent analysis that looked across a variety of types of insurance — not just ACA plans — the American Medical Association concluded that most areas are highly concentrated, with about 47% of those markets having one insurer with a commercial market share of 50% or more.

The AMA says such market power leads to higher premiums and results in reduced payments to doctors.

As for the marketplaces that offer ACA coverage, the number of insurers has also fluctuated over time, usually because of variations in anticipated premiums and the regulatory landscape, with a national average of nearly eight at the law’s inception, falling to 5.4 in 2018, but rising to nearly 10 nationally in 2025, according to KFF. Because that’s an average, some states, such as Texas, have 15 insurers, while seven states — Alaska, Arkansas, Connecticut, Hawaii, Rhode Island, Vermont, West Virginia — and the District of Columbia have only two.

Premium increases aren’t new either, nor are they hitting only ACA plans.

In fact, premiums for people buying their own coverage and those for workers who get insurance through an employer have almost always risen yearly — often above inflation levels —a trend that predates the ACA.

Critics of the ACA note that premiums in the individual market were lower before the law kicked in. However, critics often don’t note how different pre-ACA coverage was for people in the individual market, which could make it less expensive. Before the law, for example, insurers could reject people with preexisting health conditions, charge women more than men, and set annual or lifetime dollar limits on coverage. After 2014, that wasn’t allowed in ACA plans.

Average premiums for the benchmark “silver” ACA plans have gone from $481 nationally in 2018 to $497 in 2025, according to KFF. The average monthly premium jumps to $625 next year, partly because of insurers’ expectations of higher costs and a decline in enrollment if Congress does not extend the more generous tax subsidies. Those are averages, and prices will vary across the country depending on such things as age, location, and household income.

The conservative Paragon Health Institute notes that rising premiums mean larger taxpayer-supported subsidies. Deductibles, too, have gone up, with people on “bronze” plans, which have the lowest premiums, facing an average $7,476 deductible next year, compared with $5,113 in 2014.

The Cost-Consolidation Link

A 2025 Health and Human Services report, issued during the last days of the Biden administration, found the trend of highly concentrated hospital services in most metropolitan statistical areas had started before and continued after the ACA. Prices also rose. The report, which noted the role of private equity firms in consolidation efforts, also cited studies showing physicians increasingly merged — with one another, hospitals, or private equity-backed firms.

That’s important because the largest share of health care spending in the U.S. goes to hospital care, with physician services not far behind.

For Kahn, at the hospital federation, the real reason behind the mergers is financial: Many hospitals, he says, had to expand their reach or risk going under.

“Many health economists are my best friends,” Kahn said, “but they have tunnel vision when they look at the health system.” Hospitals must have sufficient revenue streams to cover the cost of patient care, he said, and consolidation is their way to respond “to all of the burdens and requirements and demands” they face.

While there is no question that health care consolidation has happened, much of it predated the ACA, Melnick said.

“At the end of the day, the ACA market never became that big to drive the overall restructuring of the industry,” he said. “A lot of what they are attributing to the ACA would have happened anyway.”

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The third time, he sought help from an insurance agent, who got Jones on the phone with the federal healthcare.gov call center to sort things out. During that call, “literally, there was someone opening a new policy without my consent,” Jones said.

Despite new rules that went into effect in mid-2024 aimed at thwarting such unauthorized ACA changes, it’s still happening, said Florida-based agent Jason Fine, who is trying to help Jones and dozens of other clients unravel such switches.

The Government Accountability Office, an independent government watchdog, on Dec. 3 issued a sharply critical, though preliminary, report saying that years of similar GAO warnings to federal officials have not produced results needed to better protect against ACA enrollment fraud. Alarms were raised during the Obama and Biden administrations, as well as the first Trump administration.

There were more than 275,000 complaints to the Centers for Medicare & Medicaid Services about unauthorized ACA enrollments and plan-switching in 2024, according to the agency, which also administers Obamacare coverage.

“The absolute bottom line is nothing has changed in terms of risk,” Seto J. Bagdoyan, a co-author of the GAO report, said in an interview with KFF Health News. Bagdoyan is the director of audit services for the agency’s Forensic Audits and Investigative Service team.

The report landed as Congress continues to be embroiled in the issue of whether to extend the more generous tax subsidies that have given consumers extra help paying their Obamacare premiums in recent years. Some ACA critics have said the subsidies fuel enrollment fraud.

Citing fraud concerns, GOP lawmakers included measures in their One Big Beautiful Bill Act that will make it harder to enroll in ACA plans in future years, such as requiring additional eligibility verification. But lawmakers have not adopted legislation introduced by Democrats to impose criminal penalties on brokers who knowingly submit false information on ACA enrollments.

“None of the Republicans making political hay out of this report have co-sponsored that legislation or offered any similar measures,” Sen. Ron Wyden (D-Ore.) said in a statement to KFF Health News. Wyden is one of the sponsors of the legislation.

The GAO inquiry, during which investigators attempted to submit enrollments using false information, was requested more than a year ago by Republicans from three House committees: Energy and Commerce, Judiciary, and Ways and Means.

The lawmakers asked for findings that could be made public now, even though the final report and any recommendations it will contain won’t be completed until the spring or summer of 2026. A hearing to consider the findings was set by House members for Dec. 10.

The report notes that federal officials estimate that $124 billion in tax subsidies were paid in 2024 for nearly 20 million ACA enrollments.

It highlighted some stunning findings. One Social Security number, for instance, was found to have been used for 125 policies in 2023.

However, the number of policies flagged as potentially compromised by rogue sales agents was far smaller than the estimates of some of the program’s biggest critics. The GAO identified about 160,000 cases in 2024, or 1.5% of the ACA applications. Some conservative analysts have broadly estimated that unauthorized enrollments that year numbered in the millions, a finding that has drawn pushback from groups representing insurers, brokers, and hospitals.

The GAO report does not quantify how much fraud there is, Bagdoyan said: “What it’s focusing on are indicators of potential fraud.”

CMS Anti-Fraud Efforts Fall Short

By October 2024, following consumer complaints, CMS suspended about 850 insurance brokers over questions about whether they had been involved with unauthorized enrollment. All were eventually reinstated, CMS told the GAO in May. Also last October, the GAO submitted the first four of its fake applications, seeking coverage for the final months of the year.

A few months earlier, in July 2024, CMS began requiring three-way calls with consumers, the marketplace, and their agents for certain types of changes, such as plan switches. Unauthorized plan-switching nets rogue agents a sales commission, and it can also lead to problems for consumers, such as losing access to their doctors or facing tax bills if they were improperly enrolled with subsidies, as KFF Health News reported in 2024.

However, the GAO reported that many agents told them those rules had a lot of loopholes, such as the federal marketplace taking only “limited steps to verify the identity of the consumer on the three-way call,” for instance asking only for publicly available information such as a name and date of birth.

Also, new ACA applicants were exempt from the three-way call rule, which leaves open the possibility of agents saying it’s a new consumer when it isn’t.

“The three-way call is something CMS has promoted,” Bagdoyan said. “It’s better than nothing, but as we point out in the report, it could be easy to overcome by an unscrupulous broker who starts the process from scratch. Or they could impersonate.”

Fine, the agent in Florida, said he alone has filed dozens of complaints with federal and state officials, often showing clients’ records being accessed or changed by multiple agents, sometimes on the same day, even after the CMS rules on plan-switching went into effect.

In one such fraud complaint, Fine listed three marketplace applications tied to one client’s name in which other agents had changed his coverage and included false income information. The client didn’t recall talking with any of those other agents, Fine wrote.

A marketplace representative who was helping Fine restore that client’s coverage told Fine that he often hears agents pretending to be the consumer, sometimes even faking the voice of an opposite-sex person.

Rogue agents can fake it because questions asked by marketplace representatives to verify identity “are from the application: the person’s name, date of birth, and address,” Fine said. “That’s the ID proofing. It’s a joke.”

Asked about the effectiveness of the three-way call rule and about reports of impersonations, CMS spokesperson Catherine Howden said in a statement that “rooting out waste, fraud, and abuse is one of Dr. Oz’s top priorities,” referring to CMS Administrator Mehmet Oz. The agency “takes allegations of fraudulent or abusive conduct seriously and acts swiftly when concerning behaviors are identified or reported,” she added.

Ronnell Nolan, the president and CEO of the insurance broker lobbying group Health Agents for America, said: “Three-way calling is a bust. It needs to go away.”

Instead, she has long called for two-factor authentication, similar to systems used in banking and other industries, to ensure the person making the change is actually the policyholder or their agent.

That hasn’t happened on the federal marketplace, where the problems with unauthorized switching are concentrated.

In the 20 states, along with the District of Columbia, that run their own ACA marketplaces, such issues are not common. States say that’s because they require more types of authentication — and they also generally use their own websites for sign-ups.

Bagdoyan said the GAO report did not consider what the states might be doing differently.

“That was beyond our scope,” he said.

Devilish Details

The 26-page document outlines the GAO’s probe, in which investigators filed 20 fake enrollments, some through insurance brokers, spanning 2024 and 2025 coverage. Most were approved, even with counterfeit documents.

One attempted application was dropped by investigators when the broker stopped responding — the brokers did not know they were part of the investigation — and another was rejected by the federal marketplace after five months of coverage when required documents were not submitted. But 18 of the plans remain in place and subsidies are being sent to insurers to cover the fake people, according to Bagdoyan.

The investigation also included an analysis of enrollment data from 2023 and 2024 looking for things such as multiple uses of the same Social Security numbers, dead people’s numbers, and cases in which three or more agents submitted enrollment actions for the same person and start date, potentially indicating fraud.

Similar investigations using the filing of fictious enrollments were conducted by the GAO in earlier undercover work that began in 2014, at the start of the ACA.

The new report said that while CMS assessed fraud risks in 2018, it has not updated its assessment since then, even as enrollment in the ACA has grown significantly.

“We have documentary evidence that whatever it is they did, obviously it hasn’t worked,” Bagdoyan said, “because we encountered the same issues as 12 years ago, having to do with identity verification.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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