Texas advocates warn of ‘unprecedented’ uncertainty ahead of ACA open enrollment

Enrollment in the federal health insurance marketplace begins next month, and advocates warn uncertainty and confusion around policy changes could affect millions of Texans who depend on it for coverage.

Federal lawmakers remain at a standstill over a push to extend the enhanced premium tax credits designed to make Affordable Care Act marketplace coverage more affordable. The enhanced credits are set to expire at the end of the year, which would more than double premiums for 2026 plans.

"At this point, we're so close to open enrollment that if Congress does extend tax credits at this moment, which they absolutely should, then there will be a mad dash to try to figure out how the infrastructure of Healthcare.gov will work," said Lynn Cowles, director of health and food justice at the advocacy group Every Texan. "Issuers would likely not readjust their rates at that point."

Cowles isn't just worried about how the back-and-forth from the federal government makes an already difficult process even more confusing. During the 2025 open enrollment period, nearly 1.8 million Texans auto-enrolled in marketplace plans — accounting for 44% of returning consumers.

"In a lot these cases, people have rolled over plans with $0 monthly premiums," Cowles said.

Those people may have never opened a premium statement because there wasn't a bill for them to pay, and they may not be expecting a new bill in January, she said. Then, they may get kicked off their plans for nonpayment.

ACA enrollment in Texas has more than tripled over the last decade — driven largely by expanded subsidies introduced in 2021. The loss of those subsidies could cost up to 1.5 million Texans coverage, according to a recent report from Texas A&M University.

Cowles recommends working with local ACA navigators or a Certified Application Counselor for assistance to find a plan that works.

If coverage is too expensive, she said people should be aware of local safety net providers and clinics. That includes Federally Qualified Health Centers or FQHCs, charitable clinics, indigent care programs and hospitals with charity care programs.

Texas already has the worst uninsured rate in the country, and Cowles said she's worried about how this "unprecedented" uncertainty will affect enrollees. She also said as the uninsured population increases, it will likely increase costs for everyone as people forgo less expensive preventive care and rely on emergency rooms.

Cowles said open enrollment has happened during a government shutdown before, including during the program's first year.

"Even in 2013, when the thing was rolling out, we still had clear understandings then of … what the tax credits were going to look like for people," Cowles said. "We had stable numbers then, and we don't have those right now."

Cowles said it's difficult for people enrolled to keep up with all the information and news surrounding the marketplace right now. But for those paying attention, she said it's another example of people being left behind by lawmakers.

"The government shutdown is another representation of the variability and the fluctuation that's happening right now across all sectors of government and public life," Cowles said.