Para reducir costos, muchos cambiaron a planes de salud con deducibles altos. Estos planes ofrecen pagos mensuales más bajos, pero los pacientes pueden enfrentar gastos altos de su propio bolsillo cuando necesitan atención médica.

Estos planes son bastante comunes. En 2023, el 30% de las personas que obtenían seguro a través de su empleador tenían un plan con deducible alto, frente a solo el 4% en 2006.

Madison Burgess, una maestra de escuela primaria de San Diego, tiene seguro de salud a través de su trabajo. Pero cuando evaluó agregar a su esposo a su plan, resultó demasiado costoso, así que empezó a buscar en el mercado una opción más económica para él.

Cuanto más revisaba las opciones de planes, más abrumador le parecía. La jerga de los seguros hacía difícil entender cuánto tendría que pagar su familia si su esposo se enfermaba. (La prima es el pago mensual de tu póliza y el deducible es lo que debes pagar de tu bolsillo antes que la aseguradora comience a pagar. Generalmente los planes con primas bajas tienen deducibles altos, y viceversa).

“No sabía qué era un deducible, así que elegí lo que era barato, y ahora me arrepiento”, dijo.

A cambio de esa prima mensual más baja, la cobertura de su esposo no comenzará a pagar la mayoría de los servicios hasta que hayan gastado $5.800 en facturas médicas. Burgess no sabía que debía cumplir con el deducible antes de que el seguro cubriera parte de los gastos.

¿Cómo prepararse para pagar miles de dólares por adelantado?

Una opción es una cuenta de ahorros para la salud (HSA, por sus siglas en inglés), que permite ahorrar dinero antes de impuestos y ahora está disponible para personas inscritas en planes de menor nivel en los mercados estatales y federales, incluidos los planes bronce y de cobertura catastrófica. Estos planes suelen tener las primas más bajas en el mercado, pero los costos más altos del propio bolsillo cuando se necesita atención.

Burgess eligió un plan Bronce y no sabía que las HSA eran una opción.

“Nunca había pensado en tener que ahorrar dinero para un deducible”, dijo.

Burgess y otras personas suelen estar más preocupadas por ahorrar para gastos inesperados como reparaciones del auto, de la casa o del veterinario.

Si, como Burgess, elegiste una cobertura de salud más económica para este año y luego te diste cuenta de que debes cubrir un deducible alto, estos consejos pueden ayudar a prepararte.

1. Podrías calificar para una HSA y no saberlo.Si estás inscrito en un plan Bronce o en uno catastrófico, calificas para abrir una cuenta de ahorros para la salud. Es como una alcancía médica con beneficios fiscales. Depositas dinero antes de impuestos, lo que reduce tu ingreso gravable. El dinero crece libre de impuestos y, cuando lo usas para , esas transacciones también están libres de impuestos. A esto se le llama una “triple ventaja fiscal”.

Estas cuentas crean un fondo para futuros gastos de salud, como visitas al doctor, medicamentos recetados e incluso productos como medicinas sin receta, tampones y protector solar.

Por lo general, el dinero no puede usarse para pagar primas mensuales, pero la cuenta es tuya y puedes usarla para gastos médicos calificados para tí, tu cónyuge o tus dependientes en cualquier momento en el futuro. El dinero sigue siendo tuyo, incluso si cambias de trabajo o de plan de salud.

Una HSA no es lo mismo que una cuenta de gastos flexibles (FSA por sus siglas en inglés). Las FSA también tienen beneficios fiscales, pero solo se ofrecen a través de empleadores. El dinero vence cada año y pierdes cualquier saldo restante cuando dejas ese trabajo.

1. ¿Te interesa una HSA? Así puedes abrir una.Puedes abrir una cuenta de ahorros para la salud a través de un banco u otra institución financiera. La institución te dará una tarjeta de débito para hacer pagos desde la HSA.

Puedes en cualquier momento del año siempre que tengas un plan elegible. Puedes elegir dónde abrir la cuenta, pero revisa si hay cargos y compara opciones.

Si obtienes seguro a través de tu trabajo, tu empleador puede exigir que uses una compañía específica aprobada por el Servicio de Impuestos Internos (IRS, por sus siglas en inglés).

Muchas personas creen que no pueden aportar dinero a una HSA. Para algunos hogares, la necesidad de ahorrar para gastos médicos compite con la de pagar la renta y comprar alimentos.

Pero hay un detalle que puede hacerlo más manejable: las contribuciones no tienen que ser grandes. Incluso unos pocos dólares al mes pueden ser un comienzo.

Sin embargo, hay un límite. El IRS establece un tope anual sobre cuánto puedes aportar a una HSA. En 2026, el límite es de $4.400 para una persona, o $8.750 para un plan familiar. Dentro de ese límite, tú decides cuánto aportar.

1. Los servicios preventivos deben estar cubiertos sin costo.Todos los planes vendidos en los mercados deben cubrir sin costo para el paciente, siempre que la atención sea dentro de la red. Estos servicios incluyen vacunas de rutina y pruebas de detección de cáncer.

Más allá de la atención preventiva, entender cuánto cuestan distintos servicios puede ayudarte a decidir qué tipo de consulta médica es mejor para tus necesidades y tu presupuesto. Por ejemplo, algunos planes cobran menos por una consulta de telemedicina que por ver a tu doctor en persona.

Revisa el de tu plan para más detalles.

1. Busca atención temprano en el año.La mayoría de los deducibles reinician el 1 de enero. Programar citas o cirugías temprano en el año puede ser estratégico si descubres una afección que requiere atención continua. Si puedes pagarlo, cumplir con el deducible antes puede hacer que el resto del año sea mucho más económico, dijo Caitlin Donovan, directora senior en la Patient Advocate Foundation.
2. Considera pagar en efectivo en lugar de usar el deducible.Algunos hospitales, clínicas u otros proveedores ofrecen precios más bajos si pagas en efectivo. Tienes derecho a recibir y una explicación de cuánto costaría un servicio de salud si pagas de tu bolsillo. Pide ese cálculo antes de recibir atención. Luego compáralo con lo que te dice tu aseguradora que costaría si usas tu seguro. Si decides pagar en efectivo, deberás hacerlo en el consultorio antes de que se envíen los cargos a tu aseguradora.

Pagar en efectivo puede ahorrarte dinero, pero generalmente ese monto no contará para tu deducible ni para el máximo de gastos de tu bolsillo.

“Si no crees que vas a alcanzar tu deducible —eres joven y tu deducible es de $10.000—, negocia el precio en efectivo”, aconsejó Donovan.

1. ¿Tienes un plan de la Ley de Cuidado de Salud a Bajo Precio (ACA)? Actualiza tus ingresos y usa una HSA para evitar sorpresas fiscales.Si tienes un plan de ACA y eres elegible para subsidios, ten en cuenta lo siguiente: si y no actualizas tu solicitud en el mercado, podrías deber miles de dólares al momento de declarar impuestos. La : reporta aumentos de salario, nuevos trabajos o ingresos adicionales cuando ocurran. Si tus ingresos aumentan, ahorrar dinero en una HSA puede ayudar, ya que ese dinero no cuenta como ingreso gravable.

Cuando reportas un aumento en tus ingresos, eso puede significar primas más altas (si ya no calificas para el mismo subsidio), pero los expertos dicen que es mejor pagar más ahora que enfrentar una gran factura después.

“Uno de los mayores problemas que veo es que alguien queda desempleado, se inscribe en un plan diciendo que no tiene ingresos, luego consigue trabajo y no lo reporta, y termina con una gran deuda de impuestos al final”, dijo Donovan.

Por eso, Donovan recomienda actualizar tu perfil en el mercado tan pronto como cambien tus ingresos, lo que también podría hacer que califiques para Medicaid o para un plan que cubra una mayor parte de tus gastos médicos.

Taylor Cook contribuyó con este artículo.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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An elementary school teacher chose a low-price health insurance plan but soon realized she wasn’t clear about what it would mean for her family’s finances.

“Once I got the insurance card, I compared our old plan to our new plan, and that’s when I really got worried, because I didn’t really understand what a deductible was. It got me thinking, how do I use this insurance?”

— Madison Burgess, 31, of San Diego

When enhanced federal subsidies expired at the end of 2025, a lot of people buying their own health insurance on the state and federal exchanges saw their expected monthly rates jump. To keep costs down, many switched to a high-deductible health plan. These plans offer lower monthly payments, but in exchange patients can face steep out-of-pocket costs when they need care.

The plans are pretty common. In 2023, 30% of people who got insurance through their employer had a high-deductible plan, up from only 4% in 2006.

Madison Burgess, a teacher in San Diego, gets health insurance through her teaching job. But when she investigated adding her husband to her plan, it was just too expensive, so she started shopping on the exchange for a cheaper option for him.

The longer she scrolled through the plan options, the more overwhelming it felt. Insurance jargon made it hard to tell what her family would owe if her husband got sick.

“I didn’t know what a deductible was, so I just went with what was cheap, and now I have regret,” she said.

In exchange for that lower monthly premium payment, her husband’s coverage won’t kick in for most care until they’ve paid $5,800 in medical bills. Burgess didn’t know that the deductible must be met before insurance picks up part of the tab.

Deductible:

The amount you as the patient have to pay before insurance picks up part of the tab

Premium:

The monthly bill for your policy, paid to the insurance company

How do you prepare for thousands of dollars in upfront costs? One option is a health savings account, or HSA, which lets you save pretax money and is now available to people enrolled in lower-tier state and federal exchange plans, including bronze and catastrophic coverage. These plans generally have the lowest premiums on the exchange but the highest out-of-pocket costs when you need care.

Burgess had chosen a bronze plan and didn’t know HSAs were an option.

“I’ve never thought about having to put money away for a deductible,” she said.

Burgess and others are often more worried about socking away money for unexpected car and house repairs or vet bills.

If, like Burgess, you chose cheaper health coverage for this year only to discover you’re on the hook for meeting a high deductible, these tips can help you prepare.

1. You might qualify for an HSA and not know it.

If you’re enrolled in a bronze or catastrophic plan, you qualify to open a health savings account. Think of it as a medical piggy bank with tax perks. You put in pretax money, which lowers your taxable income. The money grows tax-free, and when you spend it on , those transactions are also tax-free. That’s what people call a “triple tax advantage.”

These accounts build a cushion for future health costs, such as doctor visits, prescriptions, and even products like over-the-counter medicine, tampons, and sunscreen.

The money typically can’t be used for monthly premiums, but the account is yours to use for qualified medical expenses for yourself, your spouse, or your dependents anytime in the future. The money in the account is yours, even if you change jobs or health plans.

An HSA is not the same as a flexible spending account, or FSA. FSAs are tax-advantaged too but are offered only through employers. The money expires annually and you lose any remaining money when you leave that job.

2. HSA-curious? Here’s how to open one.

You open a health savings account through a bank or other financial institution. The institution will issue you a debit card so you can make purchases from the HSA.

You can at any point during the year as long as you’re covered by an eligible plan. You can choose where to open the account, but be sure to check for any fees financial institutions charge and shop around.

If you get insurance through your job, your employer may require you to use a specific IRS-approved company.

Many people decide they can’t afford to contribute to an HSA. For some households, the desire to set aside money for medical expenses competes with the need to pay rent and buy groceries.

But there’s a detail that can make it feel more manageable. Contributions don’t have to be large. Just a few dollars a month can get you started.

There is, however, a limit. The IRS sets an annual cap on how much you’re allowed to contribute to an HSA. In 2026, an individual is limited to $4,400, or $8,750 for a family plan. Under that ceiling, the amount is up to you.

3. Preventive services should be covered at no cost to you.

All plans sold on marketplaces must cover at no cost to the patient as long as the care is provided in-network. Those services include routine immunizations and cancer screenings.

Beyond preventive care, understanding what different services cost can help you decide which type of medical appointment works best for your health needs and your wallet. For example, some plans charge less for a telehealth visit than to see your primary care doctor in person.

Check out your for more details.

4. Seek care early in the year.

Most deductibles reset on Jan. 1. Scheduling appointments or surgeries early in the year can be strategic if you discover a condition that requires ongoing care. If you can afford it, meeting your deductible sooner can make the rest of the year significantly cheaper, said Caitlin Donovan, a senior director at the Patient Advocate Foundation.

5. Consider paying cash instead of spending down your deductible.

Some hospitals, clinics, or other providers offer cheaper prices if you pay cash. You have the and explanation of how much a health service would cost if you paid out-of-pocket. Ask for the estimate before you get care. Then, compare that price with what your insurance company tells you it would cost if you used your insurance. If you decide to go with a cash payment, you’ll need to pay while you’re still at the doctor’s office, before charges get submitted to your insurance company.

Paying cash may save you money, but the amount you pay generally won’t count toward your deductible or out-of-pocket maximum.

“If you don’t think you’re ever going to hit your deductible — you’re that young invincible, and your deductible is $10,000 — negotiate the cash price,” Donovan said.

6. On an ACA plan? Update your income and use an HSA to avoid a tax surprise.

If you’re on an ACA plan and you’re eligible for subsidies, be aware: If your and you don’t update your marketplace application, you could owe thousands of dollars at tax time. The . Report raises, new jobs, or side gigs as they happen. If your income goes up, stashing money in an HSA can help because the money you put in the account doesn’t count toward your taxable income.

As soon as you report an increase in your income, that could mean higher premiums (if you no longer qualify for the same subsidy), but experts say it’s better to pay now than owe a big bill that you have to pay all at once.

“One of the biggest problems I see is someone is newly unemployed and they sign up for coverage, they say that they’re not making any money, and then eventually they get a job and don’t report it, and then they have this huge tax bill at the end,” Donovan said.

She advises updating your marketplace profile as soon as your income changes, which could newly qualify you for Medicaid or a plan that contributes more toward your medical bills.

Taylor Cook contributed to this report.

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and ºÚÁϳԹÏÍø News.

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“I call it the unaffordable care act,” he said. He reprised the line in his address, blaming “the crushing cost of health care” on Obamacare. 

Trump’s words play off an ongoing congressional debate that began late last year, ahead of the expiration of the enhanced tax subsidies that had lowered the cost of ACA insurance for millions of Americans. 

Democrats, looking toward the November midterm elections, continue to use that lapse to focus public attention on affordability. 

Republicans take a different view, routinely pointing to specific provisions as culprits. Among them, the law’s essential health benefits mandate, which says Obamacare plans must cover certain basic services — including emergency care, hospitalization, maternity care, and prescription drugs — without annual or lifetime dollar limits while enrolled. 

But my colleague Sarah Boden and I found that connecting EHBs to the premium increases consumers are feeling is not a straight line. 

For starters, it’s clear that ACA premiums have increased. 

An analysis by the right-leaning Paragon Health Institute shows that the average Obamacare premium for a 50-year-old since 2014. The average premium for employer-based plans grew 68% during the same period. 

Still, that’s not the whole picture.

Pre-ACA, coverage offered by employer plans was generally more generous and, therefore, costlier than coverage under individual market plans. Individual plans were cheaper also because they could bar applicants with health problems. Beginning in 2014, the ACA forced individual policies to look more like employer plans. As a result, premiums rose — sometimes faster than those of job-based plans. 

, however, were on the rise before the ACA took effect. 

An analysis by Jonathan Gruber at the Massachusetts Institute of Technology found that premiums grew by at least 10% a year from 2008 to 2010. 

So do EHBs raise premiums? In some ways, yes, compared with pre-ACA plans that might not have covered now-required services like maternity care or prescription drugs. 

But in other ways, EHBs can save money because they’ve increased access to preventive care, said , a professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health. 

Joseph Antos, a senior fellow emeritus at the conservative American Enterprise Institute, said other parts of the ACA — such as requiring insurers to accept anyone, regardless of health status, and limiting insurers’ ability to charge older people more — also played roles in boosting premiums. 

“It’s practically impossible to tease any one thing out,” Antos said.

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Still, 69% of those enrolled last year signed up again this year, often for less generous coverage. About 9% said they had to forgo insurance, according to the survey by KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

The KFF poll revisited the people who responded to of Affordable Care Act enrollees during open enrollment for ACA plans.

Steve Davis, a 64-year-old retired car salesman in Rogersville, Tennessee, who participated in both polls, said he was looking at an annual premium of about $14,000 to renew his ACA coverage this year. He didn’t qualify for enough of a tax credit to defray the cost, he said, after Congress gridlocked on an extension of more-generous subsidies put in place under President Joe Biden.

But things worked out for Davis. He landed a job at a convenience store that came with insurance, with his share costing about $100 more a month than the $300 he paid for an ACA plan last year, before the enhanced tax credits expired.

“As it happened, the Lord provided and my insurance kicked in through my employer,” he told ºÚÁϳԹÏÍø News.

In the November survey, many respondents were not sure what they would do for their health insurance in the coming year.

Some were waiting to see whether Congress would extend the enhanced premium subsidies, which had helped many people get lower-cost — or even zero-cost — health premiums.

Congress’ inaction left some consumers in a bind.

Now, the new poll found, affordability issues are hitting home as the midterm election approaches. And that might play a role in competitive districts, creating headwinds for Republicans.

Midterm Signals

Across all respondents who were registered to vote, the poll found more than half place “a lot” of blame for rising costs on Republicans in Congress (54%), with a similar share putting the same level of blame on President Donald Trump (53%). A smaller group placed a lot of the blame on congressional Democrats (34%). Among independents, a group expected to be a key factor in many districts, the percentages putting a lot of the blame on the GOP (56%) and Trump (58%) were higher.

Among Republicans, 60% placed a lot of the blame on Democrats in Congress.

“Those who have marketplace coverage, who remained on it, they’re really struggling with health care costs,” said Lunna Lopes, senior survey manager for KFF.

While more than half (55%) of returning ACA enrollees said they will have to pare back on other household expenses to cover health care costs, about 17% said they might not be able to continue paying insurance premiums throughout the year.

Overall, 80% of those who reenrolled for 2026 said their premiums, deductibles, or other costs are higher this year than last, with 51% saying they are “a lot higher.”

About three-quarters of ACA enrollees in the survey who were registered voters said the cost of health care will have an impact on their decision to vote — and on which party’s candidate they support.

Democrats were more than twice as likely as Republicans to say those costs will have a major impact on their decision.

“Democrats seem particularly more energized by health care costs than their Republican counterparts,” Lopes said.

Enrollment Tally Down

Data released Jan. 28 by federal officials showed that about 23 million people enrolled in Obamacare plans across the federal healthcare.gov marketplace and those run by states, about 1.2 million fewer than in 2025.

But it isn’t yet known how many are paying their monthly premiums on time, and many analysts expect overall enrollment numbers to fall as that data becomes available in the coming months.

For most people, having to pay more for premiums this year was mainly due to the expiration of the enhanced tax cuts, pollsters noted. Because the subsidies that remain are less generous, households have to pay more of their income toward coverage. Congressional inaction also meant the restoration of an income cap for subsidies at four times the poverty level, or $62,600 for an individual, sticking people like Davis with higher bills.

Not everyone saw increases.

Matthew Rutledge, a 32-year-old substitute teacher in Apple Valley, California, who participated in both KFF polls, said he qualified as low-income and his subsidies fully offset his monthly premium payment, just as they did last year. He does have copayments when he sees a doctor or accesses other medical care, but he told ºÚÁϳԹÏÍø News that “as long as the premium doesn’t go up, I’m fine with it.”

Rising premiums are fueled by a variety of factors, including hospital costs, doctors’ services, and the prices of drugs.

To lower premiums, insurers offer plans with higher deductibles or copayments. In the ACA, plans with lower premiums but higher deductibles are called “catastrophic” or “bronze” plans. “Silver” plans generally balance premiums and out-of-pocket spending, while the highest-premium plans with lower deductibles are “gold” or “platinum.”

About 28% of those who stayed in the ACA marketplaces switched plans, the pollsters noted.

One 56-year-old Texas man told pollsters that his family’s income exceeded the cap for subsidies, so they switched down from a gold plan to a bronze. “Even doing that, our premiums are three times what they were in 2025, with lower plan features and a higher deductible,” he said, according to a KFF poll news release.

For some, reenrolling was not a viable option.

In addition to the 9% who said they are now uninsured, about 5% said they switched to some type of non-ACA coverage.

Some people, like Davis, landed job-based coverage, while others found they qualified for Medicaid, the joint state-federal program for low-income residents.

Such churn in and out of ACA coverage is not unusual, Lopes noted. “People get a job. They get married. They age into Medicare,” the program for older or disabled people, she said.

The poll highlighted that many people dropping coverage were younger, between 18 and 29. About 14% of people in that range now say they are uninsured. 

That’s not surprising, given that younger people tend to use health coverage less. ACA insurers said one reason they raised premiums this year was because they expected more young or healthy people to drop out, leaving them with a higher share of older, more costly enrollees. Among those 50 or older, the poll found that only 7% are now uninsured.

GOP critics of the now-expired enhanced subsidies say they were always meant to be temporary. Extending them would have cost about $350 billion from 2026 to 2035, .

But not extending them means more people will become uninsured. The CBO said the extension would have meant 3.8 million more people having insurance coverage in 2035.

KFF pollsters, in February and early March, surveyed 1,117 U.S. adults, more than 80% of the ACA enrollees originally polled in November, online and by telephone. The margin of error is plus or minus four percentage points for the full sample.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact ºÚÁϳԹÏÍø News and share your story.

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“I call it the unaffordable care act,” he said. He reprised the line in his address, blaming “the crushing cost of health care” on Obamacare.

Trump’s words also play off an ongoing congressional debate that began late last year with the expiration of the enhanced tax subsidies that had lowered the cost of ACA insurance for millions of Americans — and thrust the issue of ACA-related costs back to center stage.

Without those enhanced subsidies, the amount people pay toward monthly Obamacare premiums doubled, on average. The number of people enrolled in ACA coverage for this year has dropped by more than a million, and experts say more people could abandon coverage once premiums come due. Democrats are using this development to crank up the heat on Republicans ahead of the November elections and steer the conversation on the affordability issue.

Republicans fault the law itself for driving up these costs. For instance, Rep. Mike Lawler (R-N.Y.) that premiums “skyrocketed across the country since it took effect.”

Critics routinely point to several provisions within the ACA as the culprits — among them, essential health benefits, or EHBs. Under the law, Obamacare plans must cover certain essential services, including emergency care, hospitalization, maternity, and prescription drugs, without annual or lifetime dollar limits. But connecting EHBs to the premium increases felt by consumers is not straightforward.

Here’s a primer on key issues involved.

Checking the Numbers

It’s clear that Obamacare premiums have increased.

An analysis by the right-leaning Paragon Health Institute shows that the average premium for a 50-year-old with Obamacare since 2014. The average premium for employer-based plans grew 68% during that same time.

Paragon’s president, , told ºÚÁϳԹÏÍø News that this shows the ACA has made health care on the individual market more expensive.

Still, the comparison overlooks a couple of points. Pre-ACA, employer plans generally offered more generous coverage than individual market plans, so work-based coverage cost more. And individual plans were cheaper in part because they could bar applicants with health problems. Beginning in 2014, the ACA forced individual policies to look more like employer plans, covering a broader range of benefits and accepting both healthy and unhealthy applicants. As a result, premiums rose that first year. In the years that followed, ACA plans often experienced faster growth in premiums than job-based plans. Some policy analysts say this isn’t surprising because ACA plans started at a lower dollar base and had more room to rise.

States that saw less dramatic post-ACA premium increases, such as Massachusetts and New York, already mandated that individual-market plans provide EHB-like coverage, noted , a senior research fellow at the Heritage Foundation, a conservative think tank. These states also had higher premiums due to that and other provisions, such as not allowing plans to exclude people with preexisting conditions.

“It was a combination of things,” he said.

Blase acknowledges that the two types of insurance started at different price points. But he said the percentage change over time shows that the ACA faces “underlying inflationary pressures” — including the now-expired, more generous, covid pandemic-era subsidies — that affect its policyholders more so than employer plans.

Aside from that point, however, were on the rise even before the ACA took effect.

An analysis by Jonathan Gruber at the Massachusetts Institute of Technology found that between 2008 and 2010, premiums grew by at least 10% a year and were highly variable across states and insurers.

Consumers’ Other Costs

Over time, ACA deductibles — the amounts policyholders must satisfy in a given year before insurance kicks in — have seen large increases, with “bronze” plans now averaging $7,476 annually, up from $5,113 in 2014, according to KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. Bronze plans tend to have lower premiums than the other metal-level categories — “silver,” “gold,” and “platinum” — in part because of their higher deductibles.

The Trump administration is doubling down on high-deductible plans as part of its emphasis on affordability, making it easier this year for people age 30 and up to qualify for what are called “catastrophic plans.” These come with even larger deductibles than bronze plans.

The administration pitched a broad regulatory plan for 2027 to cement those changes, saying it was designed to lower premiums and expand choices. It would raise next year’s deductibles for catastrophic plans to $15,600 a year for an individual or around $30,000 for a family. It isn’t clear how popular such plans would be. Detailed enrollment figures for this year are not yet available, but estimates indicate only about 54,000 people chose catastrophic plans in 2025, and consumers can’t use federal subsidies to purchase them.

Before this Trump proposal, though, recent data showed that the rising rate of ACA plan deductibles had not outpaced deductibles for employer plans.

The weighted average — a calculation that gives more weight to ACA plans with the most people enrolled — shows in annual deductible amounts since 2014, from $1,881 to $2,912. During that same period, deductibles in plans offered by 59%, from $1,186 to $1,886, according to KFF’s annual employer survey.

Essential What?

To be clear, the ACA’s catastrophic and bronze plans must cover essential health benefits, as do all Obamacare plans. These EHBs fall into 10 categories of medical services and were included in the ACA to ensure individual policies meet a minimum standard of coverage and are comparable to employer-based health insurance.

Preventive services, such as annual checkups, vaccines, and certain cancer screenings, must be covered at no additional cost to patients. All plans must completely cover the cost of specific vaccines, including the annual flu shot. And insurers cannot refuse to pay for emergency care provided at an out-of-network hospital. Other EHBs are subject to out-of-pocket costs, such as copays at the doctor’s office or pharmacy counter.

In some ways, EHBs save money because they’ve increased access to preventive care, said , a professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health.

Services such as cancer screenings and lab tests can lead to earlier detection of serious conditions, when treatment is less costly, and positive outcomes are more likely.

“If you look down the list of essential health benefits, I think most people would reach the judgment that those are health care services that people should have access to,” said Larry Levitt, KFF’s executive vice president for health policy.

Joseph Antos, a senior fellow emeritus at the conservative American Enterprise Institute, said ACA requirements — such as requiring insurers to accept anyone, regardless of their health status, and limiting insurers’ ability to charge older people more for coverage — also have played roles in boosting premiums.

“Really, it’s practically impossible to tease any one thing out,” Antos said.

States do have latitude to add benefits that fall under the EHB umbrella. For example, bariatric surgery is covered as an EHB in , but not in . Pennsylvania’s EHBs also don’t include hearing aids, but do.

But the Trump administration’s 2027 regulatory proposal : When “states enact benefit mandates, plan premiums must generally increase to account for the additional coverage,” it reads. It also signals that added benefits can raise consumer costs and proposes that states be required to use their own funds to offset some of those costs.

Paragon’s Blase echoed this take in his bottom line. Mandating that plans cover EHBs without annual or lifetime caps, as required under the ACA law, encourages clinicians to overbill and overprescribe, he said. That drives up premiums and means a bigger check for insurers and medical providers at the expense of taxpayers. “You just turn patients into money factories,” he said.

, a senior research fellow at Georgetown University’s Center on Health Insurance Reforms, disagrees, saying that whatever EHBs’ role, they aren’t to blame for the year-over-year premium hikes.

People aren’t consuming medical care at exponential rates just because certain services are now covered: “Me not paying anything for that colonoscopy doesn’t make me want to get more of them,” she said.

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Jamie Estrada of Albuquerque, New Mexico, twice received injections of lidocaine in his upper spine to test if a permanent nerve ablation would treat his chronic neck pain. His pain vanished — until the numbing agent wore off about six hours later. The real zinger: His insurer was billed $28,000 for each 10-minute procedure.

Mark McCullick of Longmont, Colorado, was sent for a whole-body PET scan to find out whether his prostate cancer was back. The two-hour scan showed no evidence of cancer, but the $77,000 bill sent to the company that administered his insurance alarmed him.

Medical inflation has general inflation for years, with bills for many brief, routine procedures reaching tens of thousands of dollars.

These cases highlight the questions that haunt the American health system and the patients caught in its grip: What is a reasonable price for any health care visit or procedure, and how is it determined? How hard do insurers, the purported stewards of the patient’s hard-earned health dollars, fight to lower charges, and how closely do they scrutinize bills for accuracy?

Smith, Estrada, and McCullick’s cases are all “chargemaster” bills, calculated from the master price list that health providers place on services. Patients who have insurance don’t generally pay them. But they matter because they are often the starting point for the negotiated price the insurer agrees is reasonable to pay for the services. Patients are typically responsible for 10% to 20% of the negotiated price, their coinsurance — and when prices are this high, that can be a big number. What’s more, those negotiated rates are difficult for patients to access (until they get the bill) and seemingly arbitrary.

Also, because health insurers can offset high outlays one year by raising premiums and deductibles the next, they have little incentive to bargain hard for good deals for the patients they cover. So patients all pay unknowingly, indirectly.

In the cases of Smith and Estrada, their insurers paid the majority without questions. Penn State’s Hershey Medical Center, which treated Smith, received $61,000, or 62% of what it charged. New Mexico Surgery Center Orthopaedics, which treated Estrada, received $46,000, or 82%.

McCullick’s insurer, on the other hand, said it would pay Intermountain Health just 28% of his $77,000 bill. Then came another curveball: The hospital, which said it had gotten preauthorization, discovered after the fact that his scan was not covered. So it billed McCullick the full chargemaster rate of $77,000 — or, it offered, he could pay the cash rate of $14,259.

In an emailed statement, Chris Bond, a spokesperson for AHIP, the leading trade group for health insurers, blamed hospitals for the trouble, saying that plans are “focused on making benefits and coverage as affordable as possible for their members,” and that: “As the largest single category per premium dollar spent, increases in the cost of hospital-based care have an outsized impact on premiums.”

In a health system in which prices can vary exponentially with little transparency, how can patients afford to get sick?

‘It Makes No Sense’

Americans as a top priority for government in 2026, according to an Associated Press-NORC poll, expressing particular concern about cost, access, and insurance coverage.

The first Trump administration required insurers and hospitals to publish files containing cash, gross, and negotiated prices for various items and services. These raw, machine-readable price lists — often hundreds of pages filled with medical billing codes — to patient-customers.

Five years later, they’ve been ingested, parsed, and enriched by academics and startups, shedding light on the often-shocking disparities in prices and how they’ve come to exist.

“When we look at the data, whether it’s from a chargemaster or what insurers paid, it’s all over the map — it makes no sense,” said Marcus Dorstel, senior vice president of operations at Turquoise Health, a price transparency startup with payers and providers as clients. “The variation is huge, even in a specific area.”

When researchers at the Johns Hopkins Bloomberg School of Public Health looked at the data, they discovered that the price different insurers pay for the same billed charges “can be three or more times different at the same hospital,” said Ge Bai, a professor of health care accounting who was among the researchers.

The prices insurers pay are determined by numerous factors, including what’s in their contracts with health systems. Some health plans, such as Smith’s, automatically pay a percentage of the hospital’s billed charges, incentivizing hospitals to increase their rates. Hershey Medical Center increased its prices for 11 common hospital billing codes by an average of about 30% from 2023 to 2025, Dan Snow, a data scientist at Turquoise Health, calculated for this article. But those prices were not much different than those of other hospitals in Pennsylvania.

In other cases, an insurer might agree to pay a health system a case rate — a standard rate for a type of care, say a colonoscopy or an inpatient stay for pneumonia.

But there’s a lucrative catch, called a “carve-out,” which refers to a particular benefit that’s negotiated and paid separately. If the hospital used expensive drugs or devices, for instance, they can be billed in addition to the bundled case rate, with no limits on hospital markups. That was the case with McCullick’s PET scan; about 80% of the charge was not for the scan, but for a new kind of drug injected before the scan to detect cancer.

Most often the final prices depend on the relative negotiating power of the insurer and the health system: Which side has enough market sway to walk away if the other doesn’t meet its demands?

Such factors “can explain the price variations and patterns that we see,” Dorstel said. “In some markets insurers are price-makers, and in others they are price-takers.”

For Insurers, Paying More Is Profitable

Insurers aren’t incentivized to lower prices, because high prices mean they “get a slice of a bigger pie,” Bai said.

By law, insurers must spend 80% or 85% of premiums on patient care. But when prices rise, they can pass on the increase to customers in the form of higher premium costs and still meet their legal obligation. So higher premiums mean less money for the patient and more profit for the insurer.

For each spinal injection Estrada received, his insurance company’s contracted rate was $23,237.50. Estrada’s coinsurance was $5,166.20. With a high-deductible plan, he was asked to pay all of that more than $5,000 bill.

When he called to challenge the big bill, he said, the surgery center’s administrator told him the charges were the result of a “legacy contract” with the insurer that is “advantageous” and “favorable” to the center.

New Mexico Surgery Center Orthopaedics’ charges are many times those of the hospital where the center’s doctors admit patients, for example; there, Estrada’s insurance company’s contracted rate for the same spinal injection is just $2,058.67. And compared with the roughly $20,000 the insurer paid for each of Estrada’s injections, other insurers pay the center about $700 for the same procedure, Snow found.

The surgery center is part of a national group that owns more than 535 surgical facilities, United Surgical Partners International, which in turn is owned by Tenet Healthcare, a for-profit health conglomerate. That kind of market dominance can lend companies the negotiating power to charge — and get paid — what they want, Bai said.

The surgery center, United Surgical Partners International, and Tenet Healthcare did not reply to multiple requests for comment from ºÚÁϳԹÏÍø News.

With charges prenegotiated, insurers have little incentive to scrutinize questionable bills. When Smith asked for an itemized bill for her surgery, she discovered that she had been billed for two surgeries: one for the ectopic pregnancy removal and another because the surgeon noticed signs of endometriosis and performed a biopsy. Both were billed at the contracted rate of $37,923.

She was livid at the charges, which to her seemed like double-dipping. “That was one surgery,” she said. “There was one incision.”

A Yale University-trained lawyer, Smith consulted the federal Centers for Medicare & Medicaid Services’ , which note the two billing codes used for her surgery generally can’t be “billed together for the same patient encounter” because one more or less is bundled with the other.

Smith said she reached out to the Penn State hospital, the insurer, and even the state attorney general without resolution. So she expects she will, reluctantly, have to pay the $5,250 coinsurance that the hospital and insurer say she owes.

In response to questions from ºÚÁϳԹÏÍø News, Scott Gilbert, a spokesperson for the health system, did not respond to the specifics of this case, but wrote: “Penn State Health recognizes that health care billing can be confusing and often overwhelming for patients. The process involves many factors, including the type of care provided, where it’s delivered and the details of a patient’s insurance coverage.”

A ‘Reasonable’ Price?

After a reporter sent multiple inquiries to Intermountain Health, McCullick said an agent asked him what would be “a reasonable amount to resolve the situation.”

Sara Quale, a spokesperson for Good Samaritan Hospital, the Intermountain affiliate where he got the PET scan, wrote: “We sincerely regret the frustration this situation has caused Mr. McCullick,” noting that “we have been in consistent contact with him and will continue to follow up as needed.”

McCullick said he wants to pay his fair share but is still trying to figure out what that is — certainly less than the different self-pay prices he’s been offered, which all top $10,000. “The fluid nature of these numbers is mind blowing,” he wrote in an email.

As for Estrada, he was so angry that he decided not to go ahead with the nerve ablation. While he was being prepped for the procedure, Estrada recalled, the physician said he had “heard he might sue” and chastised him for being a troublemaker. The hospital did not respond to a request for comment on the allegations, and Estrada said he had never threatened legal action.

Estrada got off the table and put his shirt back on. “I’m not going to let this person put a big needle into my back.”

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She and her husband, Charles, a former high school teacher who goes by Chaz, planned to retire comfortably in the three-bedroom house where they raised their kids about 60 miles northwest of Sacramento.

But early last year, the 63-year-old became unsteady on her feet. One morning in May, she woke up with slurred speech and landed in the hospital, then rapidly lost the ability to move the right side of her body.

In August, as doctors continued to puzzle over a possible diagnosis, the couple received a notice saying that on Jan. 1 their combined health care premium payments through the state insurance exchange would shoot up from $540 a month to $3,899 a month. The reason: Federal enhanced premium subsidies expiring at the end of last year would no longer offset their payment.

They immediately canceled a monthlong cruise they’d been planning with friends and looked through their retirement accounts.

“Now, instead of thinking about where we can go in our retirement, we’re asking the question, ‘Are we still going to be able to stay where we are because of the health care costs?’” said Chaz, who retired in 2021 at age 59.

Then they received more bad news. In October, at the age of 63, Jean was diagnosed with ALS, a debilitating disease that will eventually leave her unable to speak, swallow, or breathe on her own. But Jean’s condition allowed her to enroll in Medicare, the federal health insurance program that covers adults 65 and older and people with disabilities. The diagnosis saved them roughly $1,600 a month in premiums — little comfort as Jean lost her ability to walk, bathe, and dress herself.

“It’s kind of morbid that, because of my diagnosis, I got put on Medicare right away, so at least we don’t have to pay that out-of-pocket,” Jean said, sitting in a wheelchair in her living room, a quilt draped over her legs to guard against the intense chills she now often gets. “We’re not going to get buried under this.”

Yet the premiums for Chaz’s plan and her Medicare remain a significant strain on their finances. The $2,300 a month they now owe, which includes roughly $342 in premium payments for Jean’s Medicare supplemental insurance, is higher than their monthly mortgage and eats up more than a quarter of their budget.

The Franklins are among the across the nation facing greater financial pressure after Congress chose not to extend 2021 enhanced federal subsidies. That assistance helped more than double enrollment in Obamacare plans to over 24 million.

The Congressional Budget Office estimated in 2024 that, without an extension of the tax credits, the number of uninsured Americans would climb by 2.2 million this year alone. , nationwide enrollment in ACA plans was down about 1.2 million year over year, though experts say it could be months before the full effects of rising premiums are known, as people miss payments and lose coverage.

The groups hit hardest will be , , and people living in high-cost states, said , a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. The Franklins are all three.

“They fell off what we call a subsidy cliff,” Pogue said. “It’s very, very shocking, the amount that a person would have to absorb.”

That’s because the expanded tax credits made the biggest difference for people nearing retirement age who sat just above thresholds, Pogue said. People such as the Franklins, who likely wouldn’t have qualified for financial help before expanded credits were implemented, are now losing that support at a time when insurers have responded to the uncertainty by dramatically raising rates.

Roughly half of people who were expected to lose eligibility for premium tax credits were ages 50 to 64, according to an , a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Republicans who opposed the extension have said the premium assistance went directly to insurance companies rather than consumers, incentivizing fraud and wasteful coverage. They also say the enhanced subsidies, which had no upper income limit for eligibility, were far too generous in capping premium payments at 8.5% of income, no matter how much an enrollee made.

“Most Americans would agree that taxpayers should not be subsidizing the health insurance of someone making $250,000,” U.S. Rep. , a California Republican who an extension in January, wrote in an . “I cannot accept the simple extension of a program that will line the pockets of insurers and is riddled with fraud at the expense of the American taxpayer.”

Patient advocates say the premium increases and expiration of subsidies have forced people into difficult choices. “The young people who are healthy are the first to say, I’m going to roll the dice” and forgo coverage, said , executive vice president of policy and programs at the National Patient Advocate Foundation. “Those who are remaining in the system — because they have no choice — are holding off care, they’re holding off their meds, they’re going without necessary food.”

While the Franklins are getting by, they have relied on their sons to pay for a motorized recliner to assist with lifting Jean and a handicap van to transport her. Chaz, who broke a tooth a year ago, delayed fixing it because a crown would cost him $1,000.

This year, the couple will draw $36,000 more than they had anticipated from their retirement savings, most of it to cover Chaz’s insurance premiums.

“I have a nest egg,” Chaz said. “But there’s a lot of people around here who don’t.”

For a while, he was outraged.

“I wish Congress would get off their butts and solve this issue,” said Chaz, who is a registered Republican but blames both sides of the aisle. “You’re so busy bickering over stupid crap and it’s both parties pointing fingers and blaming. Where was this discussion two years ago?”

Now, Chaz said, he’s focused on making Jean, his wife of 27 years, as comfortable as possible.

Before she got sick, they did practically everything together — hiking, traveling, tai chi, amateur photography, and bug-hunting. One of her favorite specimens was the rain beetle, a fuzzy scarab-like insect that can’t feed as an adult, relying solely on fat stores from its larval stages.

In the mornings, Chaz and their sons, Charlie and Louis, take turns lifting Jean, dressing her, and helping her use the bathroom. It’ll be fodder for the counselor, she jokes to her sons, when they inevitably need therapy later in life.

Most days, Jean’s outdoor adventures rarely extend beyond being wheeled to her back patio, where she loves to watch their backyard chickens bobble around. Chaz’s stubbornness makes him a great patient advocate. Charlie always seems to know exactly when she needs a big hug, and Louis tells jokes that can still make her snort with laughter.

“I don’t know what I would do without my boys making me laugh,” she said.

In December, Chaz will turn 65, old enough to qualify for Medicare himself. “After this year — knock on wood — we should be OK,” Jean said, before pausing and shooting her husband a wry smile.

“Well, you’re gonna be OK.”

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Those preliminary numbers from the open enrollment period that ended in January are less than a third of what state officials had projected. Nevada is the third state so far to launch a public option plan, along with Colorado and Washington state. The idea is to offer lower-cost plans to consumers to expand health care access.

But researchers said plans like these are unlikely to fill the gaps left by sweeping federal changes, including the expiration of enhanced subsidies for plans bought on Affordable Care Act marketplaces.

The public option gained attention in the late 2000s when Congress considered but ultimately rejected creating a health plan funded and run by the government that would compete with private carriers in the market. The programs in Washington state, Colorado, and Nevada don’t go that far — they aren’t government-run but are private-public partnerships that compete with private insurance.

In recent years, states have considered creating public option plans to make health coverage more affordable and to reduce the number of uninsured people. Washington was the first state to launch a program, in 2021, and Colorado followed in 2023.

Washington and Colorado’s programs , including a lack of participation from clinicians, hospitals, and other care providers, as well as insurers’ rate reduction benchmarks or lower premiums compared with other plans offered on the market.

Nevada law requires that the carriers of the public option plans — Battle Born State Plans, named after a state motto — lower premium costs compared with a benchmark “silver” plan in the marketplace by 15% over the next four years.

But that amount might not make much difference to consumers with rising premium payments from the loss of the ACA’s enhanced tax credits, said Keith Mueller, director of the Rural Policy Research Institute.

“That’s not a lot of money,” Mueller said.

Three of the eight insurers on the state’s exchange, Nevada Health Link, offered the state plans during the open enrollment period.

Insurance companies plan to meet the lower premium cost requirement in Nevada by , which prompted opposition from insurance brokers in the state. In response, Nevada marketplace officials told state lawmakers in January that they will give a flat-fee reimbursement to brokers.

The public option has faced opposition among state leaders. In 2024, a state judge dismissed a lawsuit, brought by a Nevada state senator and a group that advocates for lower taxes, that challenged the public option law as unconstitutional. They have appealed to the state Supreme Court.

Federal Policy Impacts

Recent federal changes create more obstacles.

Nevada is consistently among the states with the of people who do not have health insurance coverage. Last year, in the state received the enhanced ACA tax credits, averaging $465 in savings per month, according to KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

But the enhanced tax credits expired at the end of the year, and it that lawmakers will bring them back. Nationwide ACA enrollment has decreased by so far this year, down from record-high enrollment of 24 million last year.

About 4 million people are expected to lose health coverage from the expiration of the tax credits, according to the . An additional 3 million are because of other policy changes affecting the marketplace.

, an associate research professor at the Center on Health Insurance Reforms at Georgetown University, said the changes to the ACA in the Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will make it more difficult for people to keep their coverage. These changes include more frequent enrollment paperwork to verify income and other personal information, a shortened enrollment window, and an end to automatic reenrollment.

In Nevada, the changes would amount to an losing coverage, according to KFF.

“All of that makes getting coverage on Nevada Health Link harder and more expensive than it would be otherwise,” Giovannelli said.

State officials projected ahead of open enrollment that about 35,000 people would purchase the public option plans. Of the 104,000 people who had purchased a plan on the state marketplace as of mid-January, 10,762 had enrolled in one of the public option plans, according to Nevada Health Link.

Katie Charleson, communications officer for the state health exchange, said the original enrollment estimate was based on market conditions before the recent increases in customers’ premium costs. She said that the public option plans gave people facing higher costs more choices.

“We expect enrollment in Battle Born State Plans to grow over time as awareness increases and as Nevadans continue seeking quality coverage options that help reduce costs,” Charleson said.

According to KFF, nationally the enhanced subsidies an average of $705 annually in 2024, and enrollees would save an estimated $1,016 in premium payments on average in 2026 if the subsidies were still in place. Without the subsidies, people enrolled in the ACA marketplace could be seeing their premium costs more than double.

Insights From Washington and Colorado

Washington and Colorado are not planning to alter their programs due to the expiration of the tax credits, according to government officials in those states.

Other states that had recently considered creating public options have backtracked. Minnesota officials a public option in 2024, citing funding concerns. Proposals to create public options in Maine and New Mexico also sputtered.

Washington initially saw meager enrollment in its Cascade Select public option plans; only 1% of state marketplace enrollees chose a public option plan in 2021. But that changed after lawmakers with at least one public option plan by 2023. Last year the state reported that 94,000 customers enrolled, accounting for 30% of all customers on the state marketplace. The public option plans were the lowest-premium silver plans in 31 of Washington’s 39 counties in 2024.

found that since Colorado implemented its public option, called the Colorado Option, coverage through the ACA marketplace has become more affordable for enrollees who received subsidies but more expensive for enrollees who did not.

Colorado requires all insurers offering coverage through its marketplace to include a public option that follows state guidelines. The state set premium reduction targets of 5% a year for three years beginning in 2023. Starting this year, premium costs are medical inflation.

Though the insurers offering the public option did not meet the premium reduction targets, enrollment in the Colorado Option has increased every year it has been available. Last year, the state saw record enrollment in its marketplace, with purchasing a public option plan.

Giovannelli said states are continuing to try to make health insurance more affordable and accessible, even if federal changes reduce the impact of those efforts.

“States are reacting and trying to continue to do right by their residents,” Giovannelli said, “but you can’t plug all those gaps.”

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Todo esto es parte del complejo panorama durante el período de inscripción abierta de ACA para 2026. El debate en el Congreso sobre si extender los subsidios mejorados que se otorgaron durante la administración Biden provocó y centró la atención pública en el aumento de los costos de atención médica y en el problema de quién puede pagarlos.

Los subsidios mejorados, que redujeron el porcentaje del ingreso familiar que se debía pagar por la atención médica y eliminaron el límite de ingresos para calificar, expiraron a fines del año pasado. Como resultado, casi todas las personas que compran cobertura de ACA enfrentaron un aumento en los costos. Para algunos, las primas se duplicaron o incluso más, aunque aún se mantienen subsidios menos generosos.

Muchos expertos esperaban que la inscripción en ACA disminuyera este año, después de alcanzar un récord de 24 millones de inscritos en 2025.

“Si aumentas mucho el precio de algo, la economía nos dice que muchas personas comprarán menos o simplemente no lo comprarán”, dijo Katherine Hempstead, oficial de políticas de la Robert Wood Johnson Foundation.

Lo que hay que ver ahora:

Los números iniciales no son definitivos

La (CBO, por sus siglas en inglés) advirtió al Congreso en diciembre de 2024 que si no se renovaban los subsidios mejorados, 2,2 millones de personas perderían su seguro médico en 2026, y esa cifra aumentaría en los años siguientes. Analistas del Wakely Consulting Group también optarían por no tener seguro este año.

Datos publicados el 28 de enero por funcionarios federales de aproximadamente 1.2 millones de inscripciones en comparación con el año anterior, tanto en el mercado federal de cuidadodesalud.gov como en los mercados manejados por los estados. En total, hubo 23 millones de personas inscritas, incluyendo 3.4 millones nuevas en la cobertura de ACA.

En la misma fecha del año pasado, , con 3.9 millones de nuevos participantes.

Pero hay más detrás de esos números iniciales.

Por un lado, los datos de ambos años se basan en las inscripciones hasta el 15 de enero para el mercado federal, que cerró ese día su periodo de inscripción abierta. En cambio, los datos de los mercados estatales, en la mayoría de los casos, solo incluyen inscripciones hasta el 10 o el 11 de enero, aunque algunos permitieron inscripciones . Así que los números no reflejan lo que pudo haber pasado en esos últimos días. ¿Hubo un repunte en las inscripciones en los estados? ¿O, por el contrario, aumentaron las cancelaciones?

Además, los datos iniciales incluyen tanto a personas que se inscribieron por primera vez como a quienes ya tenían cobertura y fueron reinscritos automáticamente para 2026, lo cual plantea otras dudas.

En el caso de los asegurados que fueron reinscritos, los números reales no se conocerán hasta dentro de varias semanas o meses, cuando se sepa cuántos pagaron efectivamente sus primas. Algunos tal vez no prestaron atención a los costos de su reinscripción o esperaban que el Congreso extendiera los subsidios.

Ese es un factor importante a considerar porque las estimaciones de la CBO y de Wakely sobre cuántas personas perderían su seguro se basan en proyecciones de cobertura durante todo el año, no solo en las inscripciones iniciales.

En las próximas semanas, “algunos consumidores podrían darse cuenta de que realmente no pueden pagar las primas y cancelar sus planes, mientras que las aseguradoras también podrían cancelar coberturas por falta de pago”, dijo Pat Kelly, director ejecutivo de Your Health Idaho, el mercado estatal de ACA, durante una llamada con periodistas el 22 de enero.

Grandes diferencias entre los estados

También hay cambios importantes en los otros 19 estados (y el Distrito de Columbia) que , algunos de los cuales han publicado datos más detallados sobre las inscripciones que el gobierno federal.

La mayoría de los estados registró una disminución en la inscripción para 2026 respecto al año anterior, siendo Carolina del Norte el que presentó la mayor caída, con una reducción del 22%, según datos federales.

En unos pocos estados —incluidos Nuevo México, Texas, California y Maryland—, además del Distrito de Columbia, aumentó el número de personas que eligieron planes de ACA.

El mayor incremento se dio en Nuevo México, con un aumento cercano al 14% en las personas que seleccionaron planes. En los otros estados y en Washington, D.C., los aumentos fueron de un solo dígito.

Nuevo México, de manera particular, usó fondos estatales para compensar por completo la pérdida de los subsidios federales mejorados para todos los consumidores. , como California, Colorado, Maryland y Washington, usaron fondos estatales para ayudar a algunos inscritos.

La (State Marketplace Network), un colectivo de 22 mercados estatales apoyado por la Academia Nacional de Políticas Estatales de Salud, dijo que las . Comparado con el mismo período del año anterior, las cancelaciones de planes aumentaron 83% en Colorado, las bajas se cuadruplicaron en Idaho y se duplicaron en Virginia.

Las nuevas inscripciones respecto al mismo período del año pasado, según datos estatales. En Pennsylvania, personas de 55 a 64 años —el grupo con las primas más altas— y adultos jóvenes de 26 a 34 años en mayor proporción que otros grupos de edad, según datos del estado.

“Estamos viendo tasas mucho más altas de personas que abandonan su cobertura”, señaló Devon Trolley, director ejecutivo de la Autoridad del Intercambio de Seguros de Salud de Pennsylvania (Pennsylvania Health Insurance Exchange Authority). “En los últimos dos meses tuvimos 70.000 bajas, desde personas que se jubilaron anticipadamente hasta pequeños empresarios y agricultores que no saben cómo llegar a fin de mes”.

Algunos republicanos atribuyen esta disminución a medidas contra el fraude respaldadas por la administración Trump, que incluyeron .

Aunque algunas de esas acciones fueron frenadas por un tribunal federal y no han entrado en vigencia, críticos de ACA —algunos de los cuales han publicado sobre millones de personas que habrían sido inscritas de manera inapropiada— dicen que esas medidas explican la baja. Previamente de fomentar inscripciones no autorizadas o cambios de plan motivados por comisiones de corredores de seguros.

No obstante, los estados que administran sus propios mercados de ACA informaron que había muy pocos o ningún caso de cambios no autorizados. A diferencia del mercado federal, las plataformas estatales aplican controles adicionales para evitar que los corredores accedan a la cobertura de los consumidores sin autorización.

Entre quienes no regresaron al mercado, la razón principal es el costo, dijo Mila Kofman, directora ejecutiva de la Autoridad del Intercambio de Beneficios de Salud de DC (DC Health Benefit Exchange Authority), que administra el mercado de ACA en el distrito.

“Cuando analizamos quiénes son estas personas, vemos que la mitad son pequeños empresarios”, dijo Kofman. “No se trata de personas que estén cometiendo fraude”.

Primas más bajas, deducibles más altos

En lugar de quedarse con la reinscripción automática, muchos asegurados en distintos estados optaron por cambiarse a planes “Bronce”, que tienen primas más bajas pero deducibles más altas que los planes Plata, Oro o Platino.

California reportó que el 73% de los miembros que renovaron y cambiaron de plan eligieron uno bronce, en comparación con solo el 27% en el mismo período del año pasado, según la Red de Mercados Estatales. En Maine, los planes Bronce ahora representan casi el 60% de todas las pólizas compradas.

“Las personas tienen que ver qué se ajusta a su presupuesto mensual y buscar primas más bajas”, dijo Stacey Pogue, investigadora sénior del Centro para Reformas del Seguro de Salud de la Universidad de Georgetown. “Algunos cruzan los dedos esperando no tener que usar el deducible”.

En promedio, los planes Bronce tienen un . Todos los planes de ACA están obligados a cubrir ciertos servicios preventivos —como algunas vacunas, pruebas de detección de cáncer y otros exámenes— sin copago ni deducible, pero la mayoría de los demás servicios se cubren solo después de cumplir con el deducible anual.

Los deducibles altos pueden hacer que algunos pacientes eviten buscar atención médica, señaló Hempstead.

“Tienen miedo de usar su cobertura”, dijo. “Pueden posponer algo hasta que se vuelve más grave”.

Agregó que los proveedores médicos, incluidos hospitales y doctores, se están preparando para un aumento de pacientes asegurados que no pueden pagar sus deducibles.

“Todos anticipan que los hospitales tendrán que dar más atención caritativa, lo cual afectará sus finanzas y podría obligarlos a despedir personal, cerrar o reducir servicios”, dijo.

¿Tienes dificultades para pagar tu seguro médico? ¿Has decidido renunciar a la cobertura? Haz clic aquí para contactar a ºÚÁϳԹÏÍø News y compartir tu historia.

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It’s all part of a drama that roiled the ACA’s 2026 open enrollment period. Congressional debate over whether to extend more generous subsidies made available under the Biden administration led to and focused public attention on rising health care costs and the affordability issue.

The enhanced subsidies, which expanded eligibility both by lowering the percentage of household income people had to pay toward their care and removing an income cap, expired at the end of last year. As a result, just about everyone buying ACA coverage saw their costs increase. For some, what they paid toward premiums doubled or more, even though less generous subsidies remain in place.

Many experts expected ACA enrollment, which hit a record 24 million in 2025, to fall this time around.

“If you raise the price of something a whole lot, economics tell us that a lot of people will buy less of it or not buy at all,” said Katherine Hempstead, a senior policy officer with the Robert Wood Johnson Foundation.

Here are things to watch now:

Initial Numbers Aren’t Final

The in December 2024 that not extending the enhanced subsidies would cause 2.2 million people to lose insurance in 2026, with further increases in following years. Analysts with the Wakely Consulting Group would opt out of insurance for this year.

Data released Jan. 28 by federal officials showed a year-over-year enrollments across the federal healthcare.gov marketplace and those run by states. Overall, there were 23 million enrollees, including 3.4 million new to ACA coverage.

At about the same time last year, there were , with 3.9 million new to the marketplaces.

But there’s more to it than those initial numbers.

For one thing, both years’ data was pegged to Jan. 15 for the federal marketplace, which closed its open enrollment period that day. But, the data for the states that run their own marketplaces included sign-ups in most cases only through Jan. 10 or 11, even though some held open enrollment until the . Thus, the numbers don’t reflect what might have happened in those last days. Was there a surge in state sign-ups? Or, conversely, did the marketplaces see more enrollees cancel their coverage?

Additionally, those initial numbers are a mix of newly minted ACA enrollees and existing customers, many of whom were auto-reenrolled for 2026 — which raises other issues.

For existing, reenrolled policyholders, the real figures won’t be known for weeks or months, when it becomes clear how many actually pay their premiums. Some consumers may not have focused on their reenrollment costs or may have hoped Congress would extend the subsidies.

That’s an important factor to keep in mind because the CBO and Wakely estimates of millions losing insurance were based on projections for full-year coverage, not initial sign-ups.

In the coming weeks, “consumers may find they really can’t afford the premiums and cancel their plans, while carriers may also cancel coverage for nonpayment,” said Pat Kelly, executive director of Your Health Idaho, a state-based ACA marketplace, during a Jan. 22 call with reporters.

, some of which have issued more detailed data about enrollment than the federal marketplace.

Most states saw lower enrollment for 2026 than the prior year, with the biggest drop in North Carolina, where sign-ups fell by nearly 22%, federal data shows.

In a few states — including New Mexico, Texas, California, and Maryland, as well as the District of Columbia — the number of people selecting ACA plans increased.

The jump was largest in New Mexico, with its initial number of people selecting plans up by nearly 14%. Increases were in the single digits in the other states and Washington, D.C.

New Mexico — uniquely — used its own tax dollars to fully offset the loss of the more generous federal tax subsidies for all consumers. , including California, Colorado, Maryland, and Washington, used state money to help some enrollees.

The , a collective of 22 state marketplaces supported by the National Academy for State Health Policy, said initial enrollment figures . Compared with the same time last year, outright plan cancellations are up 83% in Colorado, disenrollments are four times what they were in Idaho, and Virginia has seen cancellations double.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact ºÚÁϳԹÏÍø News and share your story.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).