Local provider braces for 2026 ACA insurance premium spike

When Keene resident Gina Pasquale saw the how much her premiums would cost for health insurance for her family of three in 2026, "it looked like a mortgage payment."

Pasquale is the executive director of the Keene-based nonprofit mental health provider Maps Counseling Services and has gotten her coverage through the Affordable Care Act's marketplace, also known as the Obamacare marketplace, for over a decade. Several of her employees and many of her clients also get health insurance through the marketplace, and are bracing for their premiums to double or triple in 2026 if a set of pandemic-era enhanced subsidies expire.

Two members of Pasquale's family have severe asthma, so health coverage is critical to them, she said. But Pasquale worries that the increased premiums wouldn't just affect her family, it would also affect the sustainability of her organization.

“People are really concerned,” she said, noting that even with the enhanced subsidies, health insurance premiums are already unaffordable for many. Since many of the organization's clients rely on the ACA marketplace to get health insurance, Pasquale said, the organization's staff is "in the same situation that our clients are in. It’s a collective community-wide and country-wide problem.”

This future of the enhanced subsidies is at the center of the federal government shutdown, which is in its sixth week as of press time. Although some Republicans in Congress support extending the subsidies, many oppose this for reasons ranging from opposition to the Affordable Care Act to the profits the subsidies bring private health insurers. Meanwhile, Democrats have largely refused to negotiate a budget that does not include extending enhanced subsidies, although negotiations between Republicans and moderate Democrats are ongoing. In 2025, the enhanced subsidies helped 49,757 people in New Hampshire get coverage, according to data from the Centers for Medicare and Medicaid Services.

Throughout the shutdown, anxiety about future premium costs has been circulating among staff at Maps Counseling Services, according to Pasquale. The shutdown has created “this worry that we hold, and we have to carry it every day."

State of ACA negotiations

When the Affordable Care Act was passed in 2010, it included a premium tax credit to help cover the cost of insurance for people buying private health insurance through the Obamacare marketplace. These original subsidies were available only for people between 133 and 400 percent of the federal poverty level.

In March 2021, then-President Joe Biden signed into law the American Rescue Plan Act, which eliminated the 400 percent limit, allowing anyone to purchase health insurance through the marketplace using ARPA's enhanced subsidies. These enhanced subsidies were called the “enhanced premium tax credits," and they also increased subsidies for the 133-400 percent federal-poverty-level group.

The enhanced premium tax credits were extended as part of the Inflation Reduction Act, which Biden signed into law in 2022. They're set to expire Dec. 31.

Since the enhanced premium tax credits were passed, the number of Americans getting insurance through the ACA marketplace doubled from 12 million in 2021 to over 24 million in 2025, according to the health policy nonprofit KFF.

U.S. Sen. Jeanne Shaheen, D-N.H., has been one of the bipartisan negotiators amid the shutdown. A health policy staffer from her office told The Sentinel that there are numerous options being explored regarding potential paths forward for some continuation of the ACA subsidies.

“If Congress doesn’t act to extend the ACA enhanced premium tax credits, it’s not just Granite Staters who get their insurance through the Marketplace that are going to see premium price hikes,” Shaheen wrote in an Oct. 29 statement to The Sentinel.

If healthy people choose to go without insurance to avoid the high costs, Shaheen said, this will create a sicker risk pool of patients. “Those costs will ripple through our state’s entire health care system increasing costs for everyone, which is why it’s imperative that we work to reopen the government immediately and ensure people can keep their health insurance.”

In an interview with The Sentinel, U.S. Rep. Maggie Goodlander, D-N.H., referenced this potential "death spiral" — a term that refers to the rise in overall insurance costs when generally healthy, younger low-risk people forgo health coverage — in saying that some Republican House members actually support extending the enhanced premium subsidies.

“These are people who are clearly on the record not wanting anything to do with the Affordable Care Act, but we know that the support is there,” Goodlander said. Extending the enhanced subsidies, Goodlander believes, is crucial "at a moment when our health care system is already under critical strain and stress."

Speaking Thursday on the Senate floor, Senate Majority Leader John Thune, R-S.D., blamed Democrats for the shutdown. "Democrats of course have claimed their decision to shut down the government is about health care, and want Republicans to bail out their Obamacare mess," he said.

Regardless of the outcome of the shutdown, a jump in health insurance premiums across the state is inevitable given the Nov. 1 start of open enrollment, Shaheen's staffer noted. The open enrollment period for health insurance ends Dec. 15 for coverage beginning Jan. 1.

“This isn’t just a payout for insurance companies,” the staffer said. “This is security for everyday people.”

Local effects

Meanwhile in Keene, Pasquale is bracing for the enhanced subsidies to end. Although the impacts have yet to be seen, she and her staff fear they could be crushing.

“My major concern is I'm going to lose employees as a result, because they simply won’t be able to afford health insurance while paying their mortgages, paying their rent, buying their groceries,” Pasquale said. Even with the enhanced Affordable Care Act subsidies, employees "make financial sacrifices in their lives to work here in the first place.”

According to a KFF calculator that estimates the the cost of premiums with and without the subsidies, a single adult living in New Hampshire earning $40,000 per year would see their monthly premiums increase by $146 per month next year. A married couple in New Hampshire with two children earning $80,000 per year would see their monthly premiums increase by $297 per month.

For Maps employees, “the amount of their paycheck that then is going to have to go towards health care is going to be untenable," Pasquale said.

And if they were unable to afford health insurance on the marketplace, she predicted some employees might seek employment at places that offer health plans. “We'll have employees who have to, but don't want to, seek other employment where they can get health care through an employer, which are the big corporate groups that do mental health practice.”

In her interview with The Sentinel, Goodlander said the increase in the uninsured population would mean an increase in the number of emergency room visits. This would create worse health outcomes and be more costly to taxpayers, Goodlander noted, who met with local health care leaders at Mondanock Family Services on Oct. 29.

“The expiration of these subsidies would mean MFS would more than likely see an increase in our uninsured rate,” Mindy Asbury, Monadnock Family Services' chief medical officer, wrote in response to questions from The Sentinel. “For patients, this would mean reduced services and higher bills.”

To support clients losing coverage because of the expiration of the enhanced subsidies, Pasquale anticipates Maps will have to rely more heavily on its Hope and Healing Fund, which is funded by donors and designed to support individuals who don’t have insurance.

But if her employees have to leave to find health insurance elsewhere, patients who have insurance could lose access to care through that provider, Pasquale said.

“There's a cascade of very difficult things that come down when people are not getting adequate mental health care: increases in domestic violence, increases in child abuse, substance abuse, and so on," Pasquale said.

The situation, Pasquale described, is “heartbreaking," as she and other health care providers aren’t yet sure what the future of the enhanced subsidies will be. But “my hope is that [lawmakers] remember how many of us, how many of the citizens are impacted by this, and they figure out a way to make something happen that's affordable for all of us,” Pasquale said.

“They already have their health insurance plans. They’re fine, they’re not impacted. They might be worried for their constituents right now, but they personally are not worried.”

© 2025 The Keene Sentinel (Keene, N.H.). Visit www.sentinelsource.com. Distributed by Tribune Content Agency, LLC.