Rising ACA premiums put Texans' long-term livelihoods on the line

AUSTIN – Patrick Buchta was born with a rare liver disease that has caused several health complications throughout his life.

He signed up for the Baylor Scott & White Health Plan, the largest ACA health insurer in Texas, which sells its plans through the federal Health Insurance Marketplace.

"I got my liver transplant. … I've been able to stay within that network because I need the same specialists," said Buchta, the executive director of Austin Texas Musicians Fund, a nonprofit that advocates for local musicians. Many of them could now face higher costs or lose coverage when Affordable Care Act premium tax credit subsidies expire at the end of this month.

"There's just this general sense of underlying dread," said Buchta. "There's a lot of fear in the community. I don't think anyone really understands fully what's coming."

Buchta said he has no choice but to bite the bullet because, for him, health care is essential.

"I have to have health coverage," Buchta said. "If things go up a couple of hundred bucks, that's a couple of hundred bucks I gotta trim somewhere else, and I'm living as thin as it comes."

The ACA, commonly known as Obamacare, was signed into law in 2010 to help lower-income citizens find affordable health care.

Some enrollees are eligible for government subsidies or tax credits based on their income, which lowers monthly premiums.

Enrollment more than doubled after the American Rescue Plan Act established expanded premium tax credits during the COVID-19 pandemic.

These enhanced subsidies were designed to help low- and middle-income earners. According to KFF, nearly half of adults enrolled in ACA coverage are self-employed or run small businesses, with the largest share working as chiropractors, musicians, real estate brokers and farmers.

Although the provision was extended in 2022, the tax credits were not set to be permanent. The One Big Beautiful Bill Act does not include an extension, effectively leaving the enhanced premium tax credits to sunset by the end of the year.

Nationally, more than half of all Marketplace enrollees live in Texas, Florida, Georgia and North Carolina. Without congressional action, an estimated 1.5 million Americans might be uninsured in 2026, according to the Center on Budget and Policy Priorities, a nonpartisan research and policy institute.

Texas is uniquely vulnerable to these changes.

Texas is also one of the states that did not expand Medicaid under the ACA to cover all adults under age 65 with income up to 138% of the federal poverty level, creating a Medicaid coverage gap population: low-income individuals whose earnings are too high for Texas Medicaid but too low for the ACA Marketplace subsidies.

The pandemic-era enhanced subsidies have temporarily helped the state fill the void.

The most significant and immediate impact of the sunset will be a substantial increase in monthly premiums, according to Ankit Sanghavi, the executive director of Texas Health Institute, a public health think tank and nonprofit working to increase Texans' access to health care.

"Is care going to get expensive? Yes," Sanghavi said."Given the other costs that have gone up – on the housing side, on the food side – (this) is going to have a downstream impact on health care costs for that individual, the family, but also the system."

This means more patients could seek care with providers that serve the uninsured.

"You're going to see more people go to our safety net clinics," said Sanghavi. " It's going to strain them (the clinics) out. … It's definitely unsustainable."

Within his own organization, Sanghavi oversees employee health plans. Although the organisation is not expected to be directly affected by the upcoming changes, he said premiums have already risen by 40% to 45%.

"On the employer side, the costs are going up. In most cases, the employees will absorb the costs," Sanghavi said.

However, the ACA enhanced premium tax credits were only a provision during the COVID-19 pandemic and not meant to be a permanent change to the system, said Dr. Cliff Porter, the founder of Texas Direct Medical Care, a health care model that allows patients to pay a flat monthly fee for unlimited access to primary care services, bypassing traditional insurers.

"Part of the rhetoric is, 'Oh, these poor people aren't getting their subsidies. And all of a sudden, there'll be chaos and disaster. Tens of thousands of people die.' That's scare tactics, which really harm my patients, because they become fearful and they go, 'so I need to pay for these expensive insurance plans,'" Porter said.

Porter argues that insurers, which benefited from the ACA's rapid growth, now face losing subscribers and are adding fuel to the debate over enhanced premiums expiration.

"Part of it is the various interest groups who were getting paid from these temporary subsidies are losing it, and they're losing tens of millions of dollars," Porter said. "If you allow people to have more options, you can actually drive down costs quite tremendously."

Open enrollment for 2026 began Nov. 1, and many Texans have already seen changes in their premiums and budgets.

"They're not sure what it means for them. They're hearing about prices going up and insurance becoming unaffordable," said Erika Leos, the director of the Prosper Programs, which are run through local Foundation Communities, dedicated to helping people with financial independence, education and health coverage.

"Most of the folks that have chosen not to enroll have seen very significant increases, like double their premiums or more," Leos said. "Those are the folks who are choosing not to enroll this year."

However, a majority of Leos' clients – Austin-based low-income gig workers and small business owners – are returning from the previous year because it is "important" for them to keep health insurance.

"Even an expensive plan could be much less than the cost to cover an ongoing illness," Leos said, expressing concerns about people who said, "'OK, I can handle this extra $100 a month more … I can fit it in my budget,' but it's really causing more financial problems for them than they realized."

Foundation Communities is also partnered with Health Alliance for Austin Musicians, or HAAM, a small nonprofit that helps musicians apply for health care plans and subsidizes a portion of their costs.

"Based on the first days of open enrollment that we've had so far, we're averaging a double, based on everybody that's enrolled," said Melissa Davis, the program manager at HAAM.

"We've had people who are enrolling in health insurance, but are really concerned about how they're actually going to pay for it next year. They need the insurance, but they're trying to figure out how they are going to make it work," Davis said.

HAAM has been actively fundraising, Davis said, but like other organizations that have helped Texans secure health coverage, it is finding itself stretched thin.

Texas House Democratic Leader Rep. Gene Wu worries that high insurance premiums will kill Texans. The rates are impossible for some residents to maintain, said Wu, who represents southwest Houston.

"People that I've talked to in our communities, they're already living paycheck-to-paycheck. It's not even month-to-month anymore, it's week-to-week, day-to-day," Wu said during a press conference in October, in the midst of the government shutdown. "People are not going to survive to the end of the year."

For him, this issue is innately nonpartisan. He said raising premiums will cause drastic and consequential slashes to small business owners and local economies in Texas.

Minnesota Sen. Amy Klobuchar, also a Democrat, counts ranchers and farmers into this calculus, and said at the press conference that she is concerned about people in rural Texas, where access to health care is already a point of tension. On top of the weight tariffs have caused farmworkers to carry, these Medicaid cuts created what she called "the perfect storm of ugly."

For Wu and Klobuchar, the bottom line is clear: If people can't afford health care, they won't have it.

And the long-term implications? "This is all going to bite us in the as- in the long-run, because when people don't have (the ability) to pay these high insurance premiums, they're not gonna pay them," Wu said.

Abigail Beck contributed to the story.

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