Healthcare advocates navigate rising coverage costs after deadline

A month after the Affordable Care Act enhanced premium tax credits expired, consumers are feeling the squeeze of increased costs with many downgrading or canceling healthcare coverage.

Despite the rising costs, 22.8 million consumers still enrolled in the healthcare coverage marketplace during the open enrollment period ending on Jan. 15, the Centers for Medicare and Medicaid Services said. This included 2.8 million new enrollees in individual plans.

The figures from CMS may be encouraging on their face but the expiration of enhanced premium tax credits is driving up prices and pushing people into lesser plans. Meanwhile the Congressional Budget Office estimates that 4 million people are projected to lose coverage at some point, becoming uninsured due to being unable to keep up with the costs.

The experiences of consumers vary greatly state by state. Some states, like Maryland, passed legislation to mitigate the rising costs of coverage in the case that Congress did not extend enhanced premium tax credits.

Michele Eberle, executive director of the Maryland Health Benefit Exchange told UPI this plan passed by state lawmakers has worked exactly as intended, helping keep consumers insured. However, she said that does not tell the whole story.

"We saw a significant amount of people buy down, or they went from a really robust, low-deductible plan down to a less robust, high deductible plan," she said.

More than 16,000 people changed coverage tiers in Maryland. Of those 16,000, 34% moved from gold plans to bronze plans. This means they are going from having $1,000 deductibles to $10,000 deductibles.

About 31% of those who changed to a lower tier of coverage are over the age of 55. Forty-four percent of those consumers earn more than 400% of the poverty level, making them generally ineligible for Medicaid assistance.

In Maryland, 400% of the federal poverty level is about $60,000 for an individual or $128,000 for a family of four.

"The good news is that people want health coverage," Eberle said. "They're doing whatever they need to do to keep that health coverage. The bad news is families are taking on a tenfold financial burden for medical costs."

Due to action by the Maryland General Assembly last year, its state-based health insurance premium assistance program will lessen the blow of rising premiums for many people under 400% of the federal poverty level through 2028. Eberle has warned that it may not assist at the same level in years to come if U.S. Congress does not reinstate enhanced premium tax credits.

For the 2025-2026 open enrollment period, Maryland had the highest number of total enrollments it has ever had with more than 255,000 people signing up. It is a 3% increase over the last open enrollment period.

One of the key populations the state had a goal of keeping insured was adults 18-37. With state premium assistance, that group's participating in healthcare coverage increased by 9%.

"That's the population that is difficult to keep, to get and to retain because they're very price sensitive and they're healthy," Eberle said. "So you have to make sure they see the value in having health insurance. So, loud and clear to me, people want health insurance. They want the preventative medicine we offer through the ACA benefits to stay well. They want the free mammograms and colonoscopies, predeductible no copay, they want all of that."

As the general costs of living, including grocery, rent and utility prices, continue to rise, Eberle said that healthcare coverage is often something that people who are struggling will let go of first.

"When you get down to shelter, food and warmth, those are the things that are really important," Eberle said. "Healthcare is really important but if you have to let one of those go, many times people will lose their healthcare. Especially if they're a relatively healthy person."

The NC Navigator Consortium has been assisting people in the Tar Heel state with finding and signing up for healthcare coverage since 2013. It is a federal funded organization that also does outreach, answers questions and helps people understand the marketplace and changing policies.

Director Nicholas Riggs told UPI that many people his organization works with have been taken aback by the rising costs.

"We have a high number of folks who have gone down from a silver plan that covers 70% of out-of-pocket costs to a bronze plan that covers 60% of out-of-pocket costs," Riggs said. "People are choosing plans that don't cover as much to get a lower premium and even at a lower metal level it's still higher than what they were paying last year in a lot of cases. "So people are rightly upset."

More data on the shifts in coverage and costs should come to light in March when the Centers for Medicare and Medicaid Services releases its annual Marketplace Open Enrollment Public Use Files, Riggs added.

Marketplace navigators like Riggs prepared for the expiration of enhanced premium tax credits and the burden it would put on consumers but he said it was not until it actually came to pass that reality truly set in.

"It's more real when you're talking to human beings face-to-face and helping them dive through their specific health needs," Riggs said. "That's something that gets lost in this conversation. These are real people who have health needs who are making tough decisions of 'do I go without coverage to pay my electrical bill?'"

Even with the high costs, Riggs and his fellow navigators still encourage everyone to get some kind of coverage, though this year has been particularly challenging.

"It's just been a lot of difficult conversations this year," he said.

People choosing lower-tiered coverage plans or going without coverage altogether are more likely to experience negative health consequences. Uninsured and underinsured people are more likely to put off seeking care, making health conditions advance to a more acute state. They are also more likely to face medical debts that make personal finances even more difficult to overcome.

The states that have implemented premium assistance have done so as temporary solutions, Eberle notes. The long-term solution lies with Congress.

Lawmakers on Capitol Hill have discussed extending enhanced premium tax credits since the Dec. 31 deadline passed but no bills have advanced to put a plan into action. In the meantime, Navigators like the NC Navigator Consortium are taking more calls and helping more people than usual, despite operating at a lower capacity due to federal funding cuts.

Riggs said that the NC Navigator Consortium is at about 77% of its capacity after about 90% of its federal budget was cut. State funding has supplemented some of what was lost.

"We're helping just as many people with health coverage applications," Riggs said. "That tells me that it would be higher this year, considering the number of questions folks have about the changing landscape if we had the capacity we had last year."

If Congress were to reinstate and extend enhanced premium tax credits at a later date, Riggs said his organization will be ready to help.

Eberle said "flipping the switch back on" will depend on whether there are significant changes to the tax credits or if it is a "straightforward extension."

"The problem is not from a technology standpoint. The problem is changing behavior of individuals who have already taken action," Eberle said. "It's much harder to get someone back into coverage once they have left coverage. Even with a straight extension it's complicated from a consumer outreach standpoint."