Health insurance enrollment through the Affordable Care Act (ACA), known as Obamacare, begins Saturday with the largest cost increase expected since it took effect more than a decade ago.
More than 24 million people get their health insurance through the ACA. In 2026, a perfect storm of rising premiums and the expiration of subsidies that kept costs lower for middle-class families will mean higher bills for many people, who will be forced to look for cheaper plans or go uninsured.
“It’s a high-risk situation,” said Stacie Dusetzina, a health policy professor at Vanderbilt University in Nashville, Tennessee: “If it’s paying for food, electricity and heat versus health insurance that you don’t know if you’re going to need or not, it’s hard to keep paying, given how much it costs.”
Whether you’re renewing your coverage or signing up for the first time, here’s what you need to know as open enrollment begins.
How long is the registration period?
The enrollment period for Obamacare coverage is from November 1 to January 15 in most states.
Some have their own calendars. Idaho began its registration period on October 15 and will close registration on December 15. Massachusetts will keep registration open until January 23, Virginia until January 30, and California, New York, Rhode Island, and Washington DC until January 31.
If you want your coverage to start January 1, you must enroll by December 15 in most states. Plans selected after that day will generally take effect on February 1.
Until this year, people with lower incomes — earning up to about 150% of the federal poverty level, or about $23,500 for an individual — could sign up for coverage at any time, not just during the open enrollment period. That option is now over.
The change went into effect Aug. 25 after insurers raised concerns that some people were waiting until they got sick to sign up for coverage or then switching to a more generous plan that offered better coverage, said Cynthia Cox, director of the Obamacare program at KFF, a nonpartisan health policy research group.
The Trump administration has also revoked Obamacare coverage for DACA recipients, also known as dreamerspeople who were brought to the United States as undocumented immigrants when they were children. The dreamers They became eligible for coverage during the 2025 open enrollment period, but this was revoked in August following the change in regulations.
Why will premiums go up next year?
There are two main factors driving next year’s premium increases: the expected expiration of the ACA’s enhanced subsidies and, to a lesser extent, higher rates from insurers.
The enhanced subsidies, which went into effect in 2021, have helped millions of middle-class people pay less for their monthly premiums. This issue is at the heart of the government shutdown, and Democrats have indicated they will not vote to reopen it unless tax credits are expanded.
At the same time, insurers are raising rates for next year to address rising costs for hospital care and prescription drugs, as well as increased demand for medical services.
A KFF analysis found that insurers are raising premiums by an average of 30% in states that use HealthCare.gov, and by 17% on average in states that run their own marketplaces.
“The premium increases are the largest we have seen since the ACA exchanges were created,” said Gideon Lukens, senior researcher and director of research and data analysis for the health policy team at the Center on Budget and Policy Priorities, a nonpartisan research group. “At the same time, they are smaller than the increases in out-of-pocket expenses due to the expiration of the enhancements,” he said.
Combined with the loss of enhanced subsidies, some people could pay 114% more on average in premiums, Cox revealed. “It’s a double whammy,” he said, “not only are people losing tax credits, but they’re also paying this sharp increase in what insurers charge.”
Who is entitled to subsidies?
Before 2021, only people earning up to 400% of the federal poverty level were eligible for ACA grants.
The enhanced grants raised the income limit for eligibility, expanding eligibility to many middle-class people. People who earned more than 400% of the federal poverty level — about $78,800 for an individual or $163,200 for a family of four — could get the tax credits if their premiums exceeded about 8.5% of their income. The enhanced tax credits increased the help people received.
“The reason we call them improvements is because they expanded eligibility and also increased credit for everyone,” Lukens said, “it led to an incredible number of enrollments.”
This year, about 22.3 million people — 9 in 10 ACA beneficiaries — got the enhanced subsidies, according to government data.
Art Caplan, director of the division of medical ethics at New York University Grossman School of Medicine in New York City, said many of the people who get their insurance through Obamacare work in small businesses or are entrepreneurs. “They are family businesses,” he said.
What will happen when the subsidies expire?
The Congressional Budget Office projects that, on average, 3.8 million people will lose coverage and become uninsured each year for the next eight years.
For those who maintain their coverage, “they are likely to pay more than double what they pay now,” Lukens said.
“We will return to a system where there is a benefits cliff,” he added, “where a 60-year-old couple will no longer receive any help paying their premiums and will have to pay the full amount out of pocket.”
A 60-year-old couple earning $85,000 a year could pay about $2,000 more in premiums out of pocket, going from about $600 to about $2,600 a month, he said. A family of four earning around 130,000 could see their monthly premiums increase from around 920 to 1,900.
Can I continue to receive help to pay?
If the tax credits expire, people earning less than four times the federal poverty level — about $62,600 for an individual or $128,600 for a family of four — will still be eligible for standard ACA grants, Cox said.
But the amount of help they will receive will be significantly less, which means their premiums will also increase.
“They will still receive a subsidy,” Cox added. “They will simply receive less financial aid.”
Lukens said some low-income people who qualified for plans with no monthly premium under the enhanced subsidies could lose that benefit, and there are concerns that many of them will give up coverage.
“It is estimated that approximately one million people in this lower-income group of enrollees will likely be left uninsured if the improvements are not extended,” he explained.
Other people who no longer qualify for the tax credits could find more affordable coverage by switching from a silver plan to a bronze plan, Cox added. Bronze plans typically have lower monthly premiums but higher deductibles, meaning you’ll pay more out of pocket before coverage takes effect.
Cox advised making sure the deductible is an amount that can realistically be paid if care is needed.
“What does the deductible cover?” he asked, “Maybe there are preventive services, maybe there are doctor visits, or other things that don’t apply to the deductible. So read the fine print.”
Is it cheaper to go without health insurance?
Some people are considering this option: putting the money they would have spent on premiums into their savings.
Various experts warn that it is a risky measure. Paying cash can sometimes save money on smaller, predictable expenses, like an X-ray or a routine lab test, but health insurance is meant to protect against unexpected, high-cost emergencies. A single hospitalization or surgery can cost tens or even hundreds of thousands of dollars out of pocket.
“This is what happens when people can’t afford coverage,” explained Dr. Adam Gaffney, a critical care physician and associate professor at Harvard Medical School. “It’s not a situation that most people want to find themselves in,” he added.
Clinics known as federally qualified health centers can offer low-cost primary care to uninsured patients, and some doctors can negotiate, though they often demand payment up front, according to Michele Johnson, executive director of the Tennessee Justice Center, a nonprofit law firm and advocacy group that helps people dispute medical bills.
Cooperatives, also known as community self-insurers, can offer lower premiums and greater flexibility, Caplan added. However, they are often not regulated by the ACA and could leave members in the lurch with large medical bills, he said.
