For more than a decade, Republicans have argued that the Affordable Care Act (ACA) — often referred to as Obamacare — is irredeemably unworkable. With the so-called “big, beautiful bill,” President Donald Trump and his GOP allies have enacted policies to help make that true. Americans across the country will soon learn, if they have not already learned, that the president’s “concept of a plan” for health care is to make health insurance prohibitively expensive for millions.
The second Trump administration has drastically destabilized America’s public health bureaucracy, and the president has signed off on historic cuts to Medicaid and the broader safety net. What has drawn less public scrutiny is Republicans’ decision to let enhanced subsidies for Americans who buy health insurance through the Affordable Care Act expire.
Insurers have specifically cited federal policy changes as an impetus for imposing new financial barriers to patients.
This withdrawal of governmental assistance to purchase insurance will most likely result in younger, healthier people’s dropping out of the health insurance market, leaving enrollees to be, on average, older and sicker — and therefore more expensive to insure. To offset these sicker individuals’ higher medical costs, for-profit health insurers’ main tool is to increase the premiums they charge for everyone. Researchers at the Kaiser Family Foundation find that premiums for plans on the ACA’s marketplace will increase an average of 75% in 2026, with at least 12 states seeing premiums more than double.
While many factors can affect insurers’ setting of premiums, insurers have specifically cited federal policy changes — namely, the expiration of the Biden administration’s enhanced premium subsidies and the imposition of new tariffs — as an impetus for imposing new financial barriers to patients enrolling in coverage through their plans.
In 2010, when President Barack Obama signed the ACA, the United States had nearly 50 million uninsured, or roughly 16% of the population. At the time, insurers could deny coverage to the millions living with pre-existing medical conditions (such as diabetes, cancer, HIV/AIDS and heart disease). And many younger and healthier individuals, unable to find affordable plans, chose to risk going without health insurance (or quality health insurance).
To address this, the ACA has a trio of provisions that have been likened to a “three-legged stool.” The legislation prohibits health insurers from denying coverage (or charging more) to people with pre-existing conditions. To offset the cost of covering these sicker individuals, the ACA diversified the risk pool by creating an individual mandate to purchase health insurance. Thus, the cost of insuring less healthy enrollees is spread across all enrollees, sick and healthy alike. And as younger and healthier but often less economically secure individuals entered the risk pool, the ACA provided subsidies to offset the financial burden of premiums.
About 26 million Americans lacked health insurance in 2023 — a figure that lags behind those of countries with universal insurance but represents a vast improvement from the state of the world prior to the Affordable Care Act’s implementation. These insurance policies have been life-changing for the estimated 27% of non-elderly American adults who have pre-existing conditions. They mean new opportunities to access health care for those who cannot obtain employer-sponsored health insurance.
A sharp increase in the cost of health insurance in a country with already expensive health care comes with severe consequences.
The Tax Cuts and Jobs Act of 2017 reduced the mandate penalty to zero dollars — but instead of the proverbial stool toppling over, the ACA has remained standing on two legs, largely because of the powerful impact of the subsidies in reducing the cost of insurance. Through the American Rescue Plan of 2021 and the Inflation Reduction Act of 2022, the Biden administration implemented and extended enhanced subsidies, which reduced the cost of premiums by an average of 44%. It is perhaps unsurprising, then, that a record 24.3 million people enrolled in ACA marketplace plans for the 2025 plan year.
However, those enhanced subsidies expire at the end of 2025. To give one example of the looming premium increases, according to KFF analysts’ calculations, a non-elderly adult in Allegheny County, Pennsylvania, earning $40,000 annually would be left to pay an average of $104 per month ($1,248 per year) more for a silver plan. That is equivalent to a week or more of groceries, at least before the imposition of new tariffs (which also, incidentally, increase the cost of health care delivery — and in turn, insurance — because of more expensive drugs, devices and supplies). This added cost is a burden too great for many to bear.
A sharp increase in the cost of health insurance in a country with already expensive health care comes with severe consequences.
Health coverage through the ACA is associated with being connected to a usual source of health care, such as a primary care physician, and being able to obtain treatments that range from preventive to lifesaving. Rendering health insurance prohibitively expensive can lead people to forgo care they need — at best a problematic outcome, at worst outright dangerous. What’s more, thanks to both increased premiums and historic Medicaid cuts, millions fewer will be insured but may nevertheless seek medical attention for emergent (or seemingly emergent) conditions. Since health insurers will no longer be paying for the treatments, however, the result is that hospitals will accrue uncompensated care, harming their financial security. According to the Center for Healthcare Quality and Payment Reform, 314 rural hospitals across the United States are already at immediate risk of closure, and a rise in uncompensated care would most likely be the tipping point for many of them. If a rural hospital closes, all its patients — uninsured, publicly insured and privately insured alike — face longer driving distances for care. When health crises are time-sensitive, increasing travel times can lead to worse health outcomes. Further, hospitals employ about 6.7 million people, so hospital closures lead to job losses in those communities. In a nation heavily reliant on employer-sponsored insurance, this prospect is an ironic reminder of the importance of affordable ACA marketplace coverage that Republicans have undermined. Congressional Republicans are doing their best to turn their criticisms of the ACA into self-fulfilling prophecies. Allowing the enhanced premium subsidies to expire is another targeted attack from the GOP on well-functioning health programs that boast positive returns on investment. Those claiming to value life and fiscal responsibility should know better, but they may not care.
Miranda Yaver
Miranda Yaver is an assistant professor of health policy and management at the University of Pittsburgh and a health care fellow at the Roosevelt Institute. 
