As ACA subsidies expire, thousands drop coverage or downgrade plans

The latest data show enrollment fell about 12% in Missouri and 3.5% in Kansas for 2026. But experts say that doesn't tell the full story

By:Meg Cunningham

As small-business owners, Sonya Andrews and her husband are used to uncertainty.

Sonya runs a business offering graphic and web design services, while her husband is a commercial photographer. They also own a studio in Kansas City's West Bottoms and have one employee who works remotely from Florida.

Every month is different for them when it comes to business. But this year, they're feeling more pressure, thanks to the expiration of the enhanced premium tax credits available for Americans enrolled in the Affordable Care Act, also known as Obamacare.

Andrews and her husband also have a daughter with autism and need higher levels of coverage. Previously, they carried Aetna insurance through the marketplace, but Aetna is no longer an option for them. For 2026, as their daughter gets older and with enhanced subsidies expiring, they made the tough decision to downgrade their ACA coverage rather than pay a much higher premium.

But arriving at that decision wasn't easy. Sonya spent weeks researching and comparing plans with marketplace navigators and her husband. They're planning to closely monitor their income to make sure they don't make too much and lose their subsidies entirely, adding more pressure to the realities of owning a small business.

"I spent a lot of time trying to figure out how to make this decision," Andrews said. "You're making choices like, 'Well, we're in our mid-40s. Our daughter is young and has already had most of the expensive things done. Can we roll the dice for a few years?'"

But, unlike Andrews, tens of thousands of Missourians have opted out of the Affordable Care Act marketplace altogether after the enhanced subsidies expired.

Significant drops in enrollment 

Enhanced subsidies came into Obamacare in 2021 as part of the American Rescue Plan Act, in an effort to ease the cost of the Affordable Care Act for Americans. The enhanced subsidies were extended again through the end of 2025, but were allowed to expire ahead of open enrollment in 2026.

Without the enhanced subsidies, which offered tax credits to Americans enrolled in Obamacare, people were told they could expect an average 114% increase in their premium costs for 2026.

For someone with a household income of $55,000 (about 351% of the federal poverty line), premium costs shot up nearly $1,500 annually heading into 2026, KFF estimates.

Experts like the nonpartisan Congressional Budget Office estimated that hundreds of thousands of Americans would move away from Obamacare in 2026 as a result. Nationwide, enrollment so far has dropped by about 1.2 million people.

In Missouri, nearly 51,000 people dropped off the Affordable Care Act rolls from January 2025 through the end of the 2026 open enrollment period, the latest data from the Centers for Medicare and Medicaid Services show. Nearly 366,000 people enrolled this year, compared to 417,000 enrollees in January 2025.

Kansas had a smaller drop. Nearly 193,000 people enrolled, compared to about 200,000 who were enrolled in January of last year, the data show.

More people are enrolled in both states than in 2024, data shows.

Still, in Missouri, 50,000 people potentially without insurance is a large number when the state's uninsured population is already around 457,000, said Timothy McBride, a health care economist and professor at Washington University in St. Louis.

"That's over a 10% increase in that number," McBride said.

Plus, McBride said, the numbers don't reflect those who may have downgraded their plans to lower premiums, like the Andrews family did, or those who may disenroll or let their plans lapse by not paying their now-higher premiums.

Data compiled by Georgetown University's Center on Health Insurance Reforms found that several state-based marketplaces were reporting that Americans were canceling their plans at higher rates than in the past. In Idaho and Pennsylvania, disenrollments have so far quadrupled compared to last year, with more people citing affordability concerns.

In December, Pennsylvania's state-based marketplace reported that only 77% of enrollees had paid their initial premium for the year, compared to 88% the year before.

The impact of lower-coverage plans

Without data from the federal government on what plans people chose, it's too early to say what the impact of more bronze than silver plans will be, McBride said.

But people are generally choosing to trade lower premiums for higher deductibles, based on what Kevin Wehner, a marketplace navigator at Missouri Connections for Health, saw throughout the open enrollment period.

"The silver plan premiums were just out of reach for a lot of people," Wehner said. "They ended up switching to bronze or gold plans."

Others opted for the higher monthly premiums — up to $1,000 in some cases — or chose to become part of a health-sharing community, where a group of people all pay into a shared pot to split the cost of care.

It's a consideration Craig Heimericks and his husband have had for years, amid rising health care costs. The pair co-own rental properties around Rolla, Missouri, and the variable costs of the business constantly keep them on their toes, especially when it comes to health insurance.

"My husband and I had a plan on the exchange last year. It was great coverage, but was getting more and more expensive every year, to the point where we had been discussing ways to drop coverage and self insure," Heimericks said in an email.

"But as a business owner, the risk is just too high that one big medical event would bankrupt everything we've worked for the last 20 years. Honestly, sometimes it feels like we're being held hostage by the health care industry as a whole, and there doesn't seem to be a way out," he said.

Heimericks ended up downgrading his plan for 2026, with deductibles just under $5,000 per person and their maximum out-of-pocket costs capped at $20,300. Still, Heimericks and his husband are planning on over $1,655 a month in premiums, and they don't yet have a grasp on what the cost of their prescriptions will be under their new plan.

In 2025, they paid about $1,630 a month, but had lower deductibles and caps on out-of-pocket costs.

"The big difference was people who would normally qualify for the cost-sharing reduction would enroll in the silver plan in previous years," Wehner said. "Hardly anyone did that this year."

So far, California's state-based marketplace is seeing more people enroll in bronze plans, at 37% in 2026 compared to 23% in 2025. Other states like Maine, New Jersey and Rhode Island are reporting a higher share of customers switching to bronze plans for 2026, the Georgetown data shows.

What the data doesn't show, McBride said, was the higher deductible cost that those in Missouri and Kansas will take on.

People may have a costly health event and not expect to have to pay higher out-of-pocket costs before meeting their deductible, McBride said, which ultimately can pass the cost onto other health care customers.

"One of the things we saw early on, because the premiums were so low for bronze plans … younger people, especially healthy people, would pick that plan and have a $7,000 or $8,000 deductible," McBride said. "They'd get bad luck … and then they'd show up to the hospital and get a bill for $8,000 and they'd be like, 'Wait a minute, I thought I had Obamacare.'"

Ultimately, many aren't prepared to take on that higher cost and end up unable to pay their bills, McBride said, and that is then passed onto the consumer.

"The hospital or health system can try to get the money from them but usually can only get a fraction of it," McBride said. "Then the hospital just has to bury that cost, or shift it to the rest of us. It has a short or long-term effect on someone's health status, and it also ends up rippling to all the rest of us."

This article first appeared on Beacon: Kansas City and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.