The final day for most Americans to enroll in an Affordable Care Act (ACA) health insurance plan that begins in February passed earlier this month, closing a critical window at a moment of deep uncertainty for millions who rely on the law for coverage.
The deadline arrives as federal subsidies that once kept premiums affordable have expired, sharply increasing costs while lawmakers remain deadlocked over whether, and how, to restore them.
For people who do not receive health insurance through an employer, such as small business owners, gig workers, early retirees, farmers and stay-at-home parents, the stakes are especially high. Last year, a record 24 million Americans purchased ACA plans.
This year, enrollment has fallen behind. About 22.8 million people have signed up so far, according to federal data, roughly 800,000 fewer than at the same point last year. Both new sign-ups and returning enrollees are down.
The uncertainty has been driven largely by the expiration of expanded subsidies that originated during the Covid era and offset costs for more than 90% of enrollees. After months of debate last year, Congress failed to extend them before they expired on 1 January. As a result, the average subsidized enrollee now faces more than double the monthly premium cost for 2026, according to an analysis from the healthcare non-profit KFF.
Although the House passed a three-year extension of the subsidies this month, with 17 Republicans joining Democrats, the Senate had rejected similar legislation last year, leaving families unsure whether relief will come. Republicans’ resistance to the extension of subsidies became the main reason for the Democratic party’s holdout during the record-breaking 42-day government shutdown last year.
Last week, Trump finally unveiled his long-awaited framework for healthcare affordability, almost a year and a half after announcing during a pre-election presidential debate that he had the “concepts of a plan” for healthcare reform. The new plan was met largely with confusion and concern over the lack of detail and clear methods for realization.
Across the country, that uncertainty is translating into real-world consequences. While about 10 states with their own marketplaces have extended enrollment deadlines to later in the month, for many Americans the window is closing with no clarity in sight.
In Syracuse, New York, Jamie Buck, a 56-year-old retired firefighter who now runs a small home contracting business, says his family’s premiums have surged beyond what they can sustain. Although he receives a pension, he does not have retiree health benefits and relies on the ACA for coverage.
“With my retirement and small business income we make on average $110,000 to $120,000 annually,” Buck said. “We were paying $350 a month for both of our premiums and now have to pay $1,200 a month for the same bronze plan.”
Buck says he paid January’s premium hoping subsidies would be extended. If they are not, he plans to drop his own coverage and keep insurance only for his wife, who is one year post–breast cancer treatment, still at roughly double their former cost.
For Kristin F Simmons, a 51-year-old digital media consultant in Maine, the ACA has been essential to managing a serious, chronic illness. Diagnosed with multiple sclerosis after a sudden medical crisis in 2017, she requires ongoing, complex care that includes MRIs, spinal taps, neurologist visits and daily medication.
“With my ACA plan, I pay $10 a month for one of my medications,” Simmons said. “Without insurance, it would cost $64. A single spinal tap is $2,300. An MRI is $4,800.”
Simmons and her family of four live on an annual household income of about $44,000. With extended tax credits, they pay $245 a month in premiums. Without them, premiums in Maine are expected to rise an average of 77%, and she anticipates her family’s annual premium will rise to roughly $6,484, nearly 15% of their total income, before deductibles.
“We would face impossible choices,” she said. “Without the care that keeps me alive and functioning, I would lose my vision, my mobility, and my independence.”
Even those who have, for the moment, opted out of the ACA marketplace are feeling the pressure. In California’s Central Valley, Brian Bonnet, who recently retired at 55, found ACA premiums higher than continuing his employer plan through Cobra (a federal program allowing individuals to keep an employer’s group health insurance even after they lose their job or have a reduction in work hours).
He now pays $900 a month for health insurance, without dental or vision coverage.
“If my Cobra plan goes up too much, I will need to go back to work just for the health insurance,” Bonnet said, though he expressed concern that the job market was “not great” and that job prospects with benefits seem especially limited in his area.
In Knoxville, Tennessee, Sara Hill, a former elementary school teacher and mother of three, says her family’s monthly premium jumped from $250 in 2025 to $1,007 in 2026.
“We can pay the premium for maybe a month or two while we wait and cross our fingers that legislators will vote to renew the subsidies,” she said. “If nothing changes, we will have to cancel our plan and we don’t know if there will be any alternative available to us.”
Hill fears she may need to return to full-time work solely to find a job that offers health insurance, a move she says “will upend our lives in a major way, and take me away from the incredibly important work of raising our three children which our family has sacrificed for and prioritized for the past 12 years”.
In southern Wisconsin, Lora, a 46-year-old stay-at-home mother of five, says her family lost coverage entirely when their insurer discontinued its plan in their county, anticipating that higher costs would drive people away.
“We were paying zero for our premium, which was a godsend,” she said. “For the first time in my life, I was starting to get medical care.”
Now uninsured since the start of January, Lora says she has been unable to refill medications or seek urgent care for a tooth infection. “I’ve just been gargling with salt water, hoping it goes away.”
The only plan she can reasonably afford costs $200 a month, forcing her family to consider cutting back on basic necessities like electricity and mortgage payments to make it work.
“We already sell personal belongings to pay for food,” she said. “We don’t have support.”
