ACA Premium Spikes Will Derail Disabled People’s Careers

Now that 2026 Affordable Care Act (ACA) open enrollment is underway, millions of Americans are finding that their marketplace premiums are dramatically more expensive. Congress’ failure to extend the ACA’s enhanced premium tax credits has caused net premium costs to more than double nationwide for enrollees who receive financial assistance. As prior Center for American Progress research has highlighted, continued failure to extend the enhanced premium tax credits will particularly harm small-business owners and self-employed workers who rely on the marketplaces for affordable, comprehensive coverage. Because people with disabilities are overrepresented among the self-employed, the expiration of the credits will have especially pronounced impacts on a community already under attack. Dana Fink, a disabled federal employee who was recently one of the thousands of employees who were laid off through a reduction in force, thought about becoming self-employed but stated, “My prevailing thought really was about health insurance. I looked at the marketplace, and I am pretty much priced out of it.”*

Enhanced premium tax credits made coverage more affordable for self-employed workers

The ACA improved access to health insurance for self-employed workers who previously experienced significant barriers to coverage, including high premiums, limited plan choices, and coverage denials due to preexisting conditions. The ACA removed or alleviated many of these barriers, including by providing protections for those with preexisting conditions that are especially important for people with disabilities. Currently, 5.2 million self-employed people and other small-business owners receive coverage through ACA marketplaces.

One of the core affordability supports provided by the ACA are the premium tax credits, which provide financial support to those buying coverage via the marketplaces. Enhancements to the premium tax credits under the American Rescue Plan Act, which were further extended under the Inflation Reduction Act, provide even more support to make health coverage affordable. Unless Congress acts, those enhanced credits will expire at the end of 2025, costing the more than 4.4 million small-business owners and self-employed people who receive premium credits an average of $1,500 each annually.

Disabled people are disproportionately likely to be self-employed

As of 2023, there were nearly 1.2 million self-employed disabled people in the United States, representing more than 11 percent of employed disabled people.** Among those who are employed, disabled people are more than 50 percent more likely to be self-employed than those without disabilities. This is due to a constellation of factors, including the impact of discrimination in traditional employment, greater flexibility provided by self-employment, and self-employment allowing better ability to manage health needs. Fink stated, “Self-employment would allow me to design my workspace and schedule to maintain productivity around my health needs and would let me plan around symptom flare-ups.”* Rates of self-employment are especially high among older people with disabilities: As of 2023, nearly 1 in 5 employed disabled people age 55 or older were self-employed.

Skyrocketing premium costs will hit disabled small-business owners and self-employed people with disabilities especially hard

Increased premium costs from the loss of enhanced premium tax credits are likely to hit disabled self-employed people particularly hard. Just as disabled employees are paid less than nondisabled employees, research shows that self-employed people with disabilities earn much less than nondisabled self-employed people. This means that when premium costs rise, disabled self-employed people are especially unlikely to be able to afford the suddenly increased rates. As a result, disabled self-employed people may face increased financial struggles, be pushed into less supportive plans, or even be unable to afford the coverage their families need.

In some states, these impacts are likely to be especially pronounced. In South Dakota, 91 percent of the self-employed workers and small-business owners with marketplace coverage claimed premium tax credits in 2022—the highest rate in the country, tied with Wyoming. South Dakota also has one of the highest rates of self-employment among disabled people at 13.9 percent of employed disabled people. Similarly, 88 percent of Florida’s self-employed workers and small-business owners with marketplace coverage relied on premium tax credits—likely including many of the nearly 14 percent of employed disabled Floridians who are self-employed.**

The Trump administration and Republican congressional leaders are cutting off essential supports that allow disabled people to work

One’s health status and ability to work are intertwined. Health insurance is essential for helping people obtain and maintain employment as it improves health outcomes by facilitating access to preventive care and medical treatments. A study of Medicaid expansion in Ohio indicated that with Medicaid, those who were already working found it easier to work (83.5 percent) and those who were looking for work found it easier to keep looking (60 percent). This is unsurprising, as a majority of those on Medicaid across the United States were either working (64 percent), caring for someone (12 percent), attending school (7 percent), or too disabled to work (10 percent).

Yet the Trump administration and congressional Republicans passed legislation to strip Medicaid. Speaker Mike Johnson (R-LA) argued that work reporting requirements under Medicaid serve a “moral” purpose because “when you make young men work, it’s good for them, it’s good for their dignity.” Similarly, Trump administration leaders touted these requirements as spurring people to the “purpose and dignity” of work, which “strengthens families and communities as it gives new life to start-ups and growing businesses.” While these leaders attempt to disparage individuals on Medicaid and those without insurance, the reality is that a significant majority of families lacking insurance (73.7 percent) include at least one full-time employed individual.

The cuts to Medicaid, along with the expiration of the enhanced premium tax credits, compound the financial strains disabled workers face. Self-employed working individuals, including disabled workers, are more likely to rely on either health insurance through the marketplace or Medicaid in expansion states. Without these choices, disabled workers must either rely on work-based health insurance or leave the workforce to get on Medicaid, which has a five-month waiting period, and Social Security disability benefits. “Due to my disabilities, I have pretty high health care needs,” Fink stated. “And thus, I cannot take on contract work or any kind of … [work] that doesn’t have a fully covered 100 percent employer-backed insurance plan.”*

Conclusion

While Americans across the country—including those with disabilities—are confronting the impact of expiring enhanced premium tax credits as they seek to enroll in health insurance for next year, it is not too late to act. As a recent CAP analysis has highlighted, if Congress acts swiftly, it can restore the full credits for next year in time for marketplaces to incorporate the changes and give families real relief. People with disabilities, along with the rest of the more than 20 million people who rely on these credits to afford their coverage, are counting on their elected leaders to step up for them and their families.

*The quotations from Dana Fink were collected in an interview with the authors via Zoom on October 31, 2025. The full interview is on file with authors.

**Authors’ note: These numbers are the authors’ calculations based on American Community Survey 2023 5-year estimates and combine incorporated and unincorporated self-employment.