A 60-year-old couple earning $85,000 a year is now paying $22,600 annually for ACA marketplace coverage. That is 26% of their gross income, before copays, deductibles, or the cost of actually using the insurance. The enhanced subsidies that kept that number manageable expired at the end of 2025. The One Big Beautiful Budget Act, signed July 4, 2025, made the expiration permanent and removed the repayment caps that protected lower-income enrollees from tax-season disasters.
The average subsidized enrollee saw premiums jump from $888 to $1,904 per year, a 114% increase. That figure comes from CMS enrollment data and insurer filings, not from an advocacy group's press release. The subsidy recipient share of marketplace enrollment dropped from 92% in 2024-2025 to 87% in 2026. Healthier, younger people are leaving first. The ones staying are sicker. Every health economist who has studied adverse selection knows exactly where this trajectory ends.
The Tax Surprise Nobody Warned You About
Right now, people filing 2025 taxes are discovering they owe money back because their income estimates were off. The repayment caps for the 2025 tax year are still in place: $375 for singles below 2x the federal poverty level, up to $3,250 for families. Painful, but survivable. For the 2026 tax year, filed in 2027, those caps are gone. Cynthia Cox at KFF put it plainly: a small income shift can mean repaying the entire tax credit. The word "devastating" appeared in the WUSF reporting on this. It is not hyperbole.
Insurers are responding to the subsidy loss by narrowing networks, cutting high-cost hospitals and specialists. Two hospitals have closed in the past 6 months. Nine more are at risk in the next 6. High-end hospitals are projected to absorb $32 billion in revenue losses by end of 2026, and 12 states face significant increases in uncompensated care. A narrower network does lower premiums at the point of purchase. It does not lower the cost of getting sick.
The Fiscal Discipline Argument Deserves a Fair Hearing
Republicans framing the OBBBA as fiscal discipline have a point worth acknowledging: the enhanced subsidies were expensive, and some households above 400% FPL were receiving aid that was arguably generous by historical standards. The subsidy cliff at $62,000 for a single person is a real design flaw in the original ACA structure. I will grant that.
What I will not grant is that the solution to an imperfect subsidy structure is no subsidy structure. The proposed 2027 rules allowing ACA exchange plans without traditional networks suggest the policy direction is not reform; it is managed dismantlement. Removing repayment caps while simultaneously ending auto-reenrollment and adding pre-enrollment verification requirements is not simplification. It is attrition by paperwork.
Some states have implemented their own subsidies or premium alignment programs to offset the federal cuts. That variation is useful evidence: the damage is not inevitable. It is a policy choice, and other policy choices exist. The Senate filibuster blocked renewal efforts in 2025. That is the specific mechanism that needs to change before the 2026 midterms, and Democratic candidates in competitive Senate races should be running on exactly this number: $22,600 per year for a couple that earns $85,000.
The risk pool data will not wait for the next legislative session. Once the healthy enrollees leave and the sicker pool drives premiums higher still, the spiral becomes self-sustaining. Congress should restore the enhanced subsidies and reinstate repayment caps for tax year 2026. Not as a political gesture. Because the alternative is a documented, quantifiable public health failure unfolding in real time.
