When 2026 Affordable Care Act (ACA) marketplace open enrollment begins nationwide on November 1, millions of people who purchase coverage will confront a harsh new reality of higher premiums and fewer affordable options. The combination of the expiring enhanced premium tax credits and the Trump administration’s marketplace integrity and affordability rule threatens to undo more than a decade of the ACA’s progress in expanding coverage and reducing the number of uninsured people.
Low-income Americans, young adults, and the self-employed will be among those individuals hardest hit. Unless Congress acts swiftly, the 2026 open enrollment period could mark a turning point, when open enrollment begins to close the door on affordable coverage.
Dual affordability threats
Two policy shifts are converging to threaten marketplace coverage affordability and access in 2026 and beyond. First, the enhanced premium tax credits that lowered premiums are set to expire on December 31, 2025. Without congressional extension, average premium costs will more than double in 2026 for more than 20 million Americans who receive financial help with marketplace plans. The nonpartisan Congressional Budget Office estimates that the number of uninsured Americans will increase by about 4 million by 2034 as a result. Congressional Republicans rejected numerous opportunities to extend the enhanced tax credits through the Big Beautiful Bill, and extension negotiations have stalled amid the ongoing federal government shutdown. Second, the Trump administration’s marketplace integrity and affordability rule restricts eligibility, limits enrollment opportunities, and will likely increase enrollee costs—further shrinking the risk pool, raising insurance premiums, and making it harder for Americans to maintain comprehensive coverage.
Low-income Americans will be priced out of coverage and have fewer enrollment options
For low-income families, the expiration of the enhanced premium tax credits presents a direct and urgent threat to affordability. For low-income people earning 100 percent to 150 percent of the federal poverty level (FPL), the enhanced tax credits reduced premiums to $0 for a benchmark silver plan. In 2025, more than 10.9 million Americans in this income range are enrolled in marketplace coverage. New Center for American Progress analysis finds that 9 in 10 (92 percent) of those low-income enrollees live in states that voted for President Donald Trump in 2024, substantially exceeding the 77 percent of all enrollees who live in states that voted for Trump. These low-income enrollees are heavily concentrated in states that did not expand Medicaid under the ACA, such as Texas and Florida, where people below 138 percent of the FPL do not qualify for Medicaid and instead must rely on marketplace subsidies.
New Center for American Progress analysis finds that 9 in 10 (92 percent) of those low-income enrollees live in states that voted for President Donald Trump in 2024, substantially exceeding the 77 percent of all enrollees who live in states that voted for Trump.
If Congress does not extend the enhanced tax credits, premium costs for this population will jump from $0 to several hundred or even thousands of dollars. A Center on Budget and Policy Priorities analysis finds that a family of four earning about $45,000 (roughly 144 percent of the FPL) that paid nothing for coverage in 2025 could face annual premium costs of nearly $1,500 for silver-tier coverage in 2026. Evidence shows that even modest increases in premiums and out-of-pocket expenses can present significant financial burdens for those with lower incomes.
Compounding this increase in premium costs, the final marketplace rule eliminated the low-income special enrollment period (SEP) that allowed people with incomes up to 150 percent of the FPL to enroll in coverage year-round. This SEP had been a lifeline for a population that is more likely to be uninsured. Its elimination on August 25, 2025, means that many low-income consumers who miss the annual open enrollment window, or who lose coverage due to inability to pay midyear, will be locked out until the next year.
Young adults will face steep premium increases
The ACA expanded coverage for young adults. From 2009 to 2023, the uninsured rate for individuals ages 19 to 25 dropped from 31.5 percent to 13.1 percent, largely due to provisions that allowed young people to stay on a parent’s plan as a dependent until age 26 and access affordable coverage through the marketplaces.
Without the enhanced tax credits, premiums for young adults will rise sharply. For example, a 27-year-old single adult in Miami earning $25,000 and on a benchmark silver plan will see their premium rise from $156 to $5,052 per year—a 3,138 percent increase.* On average, in the absence of the enhanced tax credits, the Urban Institute estimates that the uninsured rate for Americans ages 19 to 34 will increase 25 percent in 2026, the largest increase among any age group.
As younger, generally healthier enrollees exit, the risk pool will become older and sicker, resulting in higher premiums for people who remain insured and destabilizing the marketplace.
Rising premiums threaten coverage gains among the self-employed and small-business owners
The ACA marketplaces are a disproportionately important source of coverage for America’s self-employed and small-business workforce. KFF estimates that in 2024, 48 percent of adult marketplace enrollees were self-employed entrepreneurs, small-business owners, or small-business employees. Affordability improvements made possible by the enhanced premium tax credits have helped drive coverage gains among the self-employed; the uninsured rate for self-employed workers fell from 20.5 percent in 2019 to a low of 17.9 percent in 2022.
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If the enhanced tax credits expire, premium costs will increase for many small-business owners and self-employed individuals. Without affordable coverage options, some employees may be forced to go uninsured, while employers may have to cut staff or scale back their operations.
Conclusion
The expiration of enhanced premium tax credits and new marketplace regulations will raise premiums, reduce enrollment, and reverse years of coverage gains. For low-income families, the loss of enhanced tax credits will make coverage unaffordable overnight, turning $0 premiums into bills of hundreds or thousands of dollars per year and forcing many to drop coverage entirely. Young adults will face steep increases in their premiums, driving healthier enrollees out of the marketplace. For small-business owners and the self-employed, higher costs and fewer plan options will make maintaining coverage—and entrepreneurship itself—more difficult. Collectively, these changes will push affordable coverage further out of reach for millions of Americans. Congress must act to extend and make permanent the enhanced premium tax credits to keep health care affordable and ensure that open enrollment truly opens the door to coverage, not closes it.
The author would like to thank Emily Gee for her contributions and Neda Ashtari for her fact-checking assistance.
* The author conducted marketplace plan window shopping on October 21, 2025. Information on the illustrative household characteristic inputs is on file with the author.