Sabrina Corlette and Karen Davenport
The Affordable Care Act (ACA) Marketplaces have had their ups and downs over the last decade, but it’s hard to find a year when consumers have faced more uncertainty going into an open enrollment period. “Window shopping” for 2026 Marketplace health plans has already begun in several states and open enrollment begins in most states on November 1. Yet the premiums people pay could change radically, if Congress finally acts to extend the enhanced premium tax credits currently slated to expire at the end of this year. While the debate over premium tax credits has shut down the government and captured the headlines, there are numerous other federally driven changes that will impact open enrollment this year. This blog walks through what consumers can expect in an unusually turbulent year for the ACA.
What Is Not Changing
Several of the Trump Administration’s major policy and operational changes to the ACA Marketplaces have not yet been implemented. Of particular importance, the administration’s plan to shorten the open enrollment period to 9 weeks has been delayed to next year. So, as in past years, consumers in the federally run Marketplace will have until January 15, 2026 to select a plan, and consumers in many state-based Marketplaces (SBM) have an even longer enrollment window.
Several other regulatory changes that would have increased the amount of documentation consumers need to prove their eligibility for the Marketplace and premium tax credits have been temporarily blocked, thanks to a federal court order. These policies could go into effect at a future date, pending the outcome of ongoing litigation, but not in time to affect this year’s enrollment period.
Changes Affecting Access and Affordability During this Year’s Open Enrollment Period
Recent legislative and regulatory actions have reduced individuals’ eligibility for Marketplace coverage and premium assistance, increased the cost of that coverage, and reduced the help available to consumers as they navigate the enrollment process.
Reduced Eligibility
One of the first regulatory actions by the Trump administration was to reverse a Biden-era policy and strip “Deferred Action for Childhood Arrivals” (DACA) recipients of eligibility to enroll, with premium tax credits, in Marketplace health plans. Beginning August 25, 2025, the Marketplaces began the process of notifying an estimated 10,000 individuals that their coverage would be terminated.
Another group of individuals slated to lose coverage are lawfully present immigrants, including green card holders, with incomes under the poverty line (earning up to $15,650/year), who are ineligible for Medicaid because they are in the 5-year waiting period for Medicaid benefits. Under the ACA, these individuals were eligible for premium tax credits through the Marketplaces. This year, Congress stripped this provision out of the ACA when it passed H.R. 1, otherwise known as the “One Big Beautiful Bill Act.” As a result of this new law, these individuals will no longer be eligible for premium tax credits beginning on January 1, 2026, rendering a Marketplace plan unaffordable for the vast majority of them. The Congressional Budget Office (CBO) estimates that 300,000 people will become uninsured as a result of this change to the ACA.
Reduced Affordability
Congress’ failure to extend the enhanced premium tax credits is expected to increase the average Marketplace enrollee’s premium by 114 percent. But the expected premium change will vary widely, depending on an individual’s age, plan, and other factors. For example:
- A family of four earning $50,000 per year living in Nashua, New Hampshire will see their premiums jump from $9 to $186 per month, an almost 2000% increase.
- Two retirees in their early 60s, living in Kaukauna, Wisconsin on an income of $85,000 per year will see their premiums jump from $602 to $2,144 per month, or 250%.
- A 28-year-old living in Hillsboro, Oregon earning $25,000 per year will see their premiums jump from $8 to $97 per month, a 1113% increase.
By the end of October, almost all state-based Marketplaces will have sent notices to current enrollees informing them of these higher premiums and reduced tax credits. However, the federally run Marketplace does not send consumer notices with information about 2026 premiums, and the Centers for Medicare & Medicaid Services (CMS) has informed insurers that, for this year at least, including that information is voluntary. As a result, many consumers in the federally run Marketplaces will not learn about premium increases unless and until they log into their HealthCare.gov accounts; those who are auto-renewed may not learn about the premium change until they receive the bill from their health plan in January.
In addition, new federal regulations finalized earlier this year, which change the formula the government uses to calculate the rate of increase for enrollees’ premium contributions, will push premiums even higher for most Marketplace enrollees. The same formula also applies to the maximum annual amount policyholders must pay out-of-pocket towards their health care, for consumers in both employer-sponsored and Marketplace health plans. As a result of this change, most Marketplace consumers can expect to pay 4.5% higher premiums in 2026 than they otherwise would have, and consumers in both employer and Marketplace plans could face a maximum out-of-pocket cap that is 15.2% higher in 2026 than it was in 2025.
Reduced Help for Consumers
Amidst these changes, the Trump administration has dramatically cut back on the support available to consumers in the federally run Marketplaces. Marketplace Navigators, non-profit enrollment experts who provide one-on-one assistance to consumers, saw their funding cut by 90 percent. Further, as a result of early efforts by the Department of Government Efficiency (DOGE), the Trump Administration eliminated jobs for CMS customer support staff.
Post-Open Enrollment Changes That Raise the Stakes for Consumers
New federal policies that will primarily impact people after open enrollment have also raised the stakes for Marketplace consumers. These policies limit special enrollment periods (SEP), expose consumers to unexpected tax liability, and reduce covered benefits.
Ending the Low-Income SEP
New federal regulations have “paused” a Biden-era policy that enabled low-income consumers (those earning below $23,475/year) to enroll in Marketplace coverage, year-round. This “low-income SEP” relieved individuals who are disproportionately likely to be uninsured from strict enrollment deadlines, thus expanding their access to coverage. With the rule change, these individuals will now need to apply for premium tax credits and select a Marketplace plan during the annual open enrollment period, or risk being uninsured for the entire year.
Although the federal regulatory change would only apply for plan year 2026, Congress permanently codified the ban on the low-income SEP in H.R. 1.
Ending Caps on Tax Liability
H.R. 1 removes current limits on the amount that low-income people must pay back to the Internal Revenue Service (IRS) if the premium tax credits paid to their insurer on their behalf exceed the amount they were eligible for, based on their actual annual income. For 2025, the repayment of premium tax credits is capped at $375 for an individual earning $31,300/year (200 percent of the federal poverty level), climbing to a cap of $1,575 for someone earning $62,600/year (400 percent of the federal poverty level). There is no repayment cap for someone earning over that amount.
The new law lifts these caps on premium tax credit repayments beginning with the 2026 tax year. This means that low- and moderate-income families could owe the IRS unexpected large amounts when they file their 2026 tax returns if their income or household size changes next year. For Marketplace applicants, it can be very difficult to accurately predict their next year’s income. Few people know a year ahead of time if they’ll get a raise, add an additional shift, work overtime, or take on a new client or side hustle. This is particularly true for low- and moderate-income families whose jobs and income can be volatile. And while the process of filing taxes and reconciling the amount of premium tax credits received against an enrollee’s actual income is a critical aspect of program integrity, the caps on the amount the iRS could collect protected low-income families from unexpectedly large tax bills, through no fault of their own. Perhaps because of the chilling effect that unanticipated tax liabilities could have on enrollees, CBO has estimated that this change to the ACA will increase the numbers of uninsured by 100,000.
Ending Coverage for Gender Affirming Care
New Trump administration rules prohibit health insurers from covering the treatment of gender dysphoria as an “essential health benefit” under the ACA, beginning in 2026. In many states, this means that transgender individuals who need these services could find themselves without coverage for these services. Some states, however, mandate coverage for this treatment either explicitly or implicitly through state-level non-discrimination standards. During this open enrollment period, individuals who may need gender affirming care services should carefully examine their plan benefits to determine what may no longer be covered.
Looking Ahead
The above policy and operational changes are only the beginning of a set of federal policies that will make it more difficult for consumers to access, afford, and maintain ACA Marketplace coverage. Consumers will need to navigate these changes with less help than in past years, thanks to reduced federal consumer assistance and staffing cutbacks. However, the consumer experience could be very different, state-to-state, as some states work to mitigate the projected coverage losses with state-funded programs and other efforts to maintain access to coverage and care.
