When open enrollment ended earlier this year, 23.1 million Americans had signed up for health coverage through the Affordable Care Act (ACA) marketplace, which is near the all-time record. Many of them are now opening monthly bills that look nothing like last year’s. A 40-year-old earning $50,000 who bought a benchmark silver plan in 2025, for instance, may have paid around $100 a month after enhanced federal subsidies. Based on examples in a Centers for Medicare and Medicaid Services (CMS) pricing fact sheet, that same plan in 2026 runs closer to $400.
Nationally, average benchmark premiums climbed 26% this year, which is the steepest single-year jump since silver plan rates spiked roughly 34% after insurers lost federal cost-sharing reduction payments in 2018. This time, however, the cause is different, but the sticker shock is familiar.
Why premiums surged
Several factors contributed to the increase in premiums. First, the enhanced premium tax credits, which was created during the pandemic and later extended by the Inflation Reduction Act, expired on December 31, 2025. Those credits had capped what most low- and moderate-income households actually owed each month, often pushing net premiums into single digits. Without them, consumers now shoulder a far larger share of the full premium, and insurers no longer have a federal backstop absorbing much of the rate increase on enrollees’ behalf.
Meanwhile, the underlying cost of medical care kept rising. Insurers pricing 2026 plans cited several pressures in their rate filings: hospital and physician reimbursement rates that continue to outpace general inflation, a lingering backlog of procedures patients deferred during the pandemic, and growing demand for behavioral health services.
One cost driver drew outsized attention: GLP-1 receptor agonist drugs like Ozempic and Wegovy, prescribed for diabetes and, increasingly, for weight management. These medications are expensive on a per-patient basis, and prescribing volumes have surged as clinical guidelines expanded and consumer awareness grew. Novo Nordisk cut Wegovy’s list price by roughly 40% in late 2025, but the Associated Press reported that many patients still face significant out-of-pocket costs. Additionally, the sheer volume of new prescriptions has kept total spending on the drug class climbing. Actuaries building 2026 rate filings had to estimate how many enrollees would begin GLP-1 therapy during the plan year and how long they would stay on it. That forecast carries wide uncertainty, and some carriers responded by pricing conservatively.
It is worth noting what the data does and does not show. No publicly available CMS breakdown isolates exactly how many percentage points of the 26% increase trace to GLP-1 spending versus hospital inflation or other factors. The connection exists and is documented in insurer rate filings and independent analyses, but a precise federal accounting is not yet available.
Who feels it most
The increase in premiums does not hit everyone equally. Consumers below 150% of the federal poverty level still qualify for standard premium tax credits that cap their costs at a small percentage of income, so many will see only modest changes to the premiums they pay. The group most exposed to rising premiums sits in the middle-income band: people earning roughly $60,000 to $100,000 as single filers who benefited from generous enhanced credits in 2025 but now fall into a gap where standard subsidies cover a much smaller share of a much higher premium.
Enrollment counselors and patient advocates across the country describe a common reaction from that group: disbelief followed by difficult math. A self-employed 52-year-old in North Carolina told the Associated Press in April 2026 that her monthly premium jumped from $87 to over $400 for the same plan. “I’m healthy, I rarely go to the doctor, and now I’m wondering whether I can justify keeping this coverage,” she said. That calculation is playing out in households nationwide.
For some individuals, downgrading from gold plans to silver plans, or from silver plans to bronze plans, may help reduce monthly premiums. Silver plans pair moderate premiums with lower deductibles, while bronze plans carry cheaper monthly payments with higher deductibles. Gold plans, on the other hand, tend to carry the highest premiums relative to silver or bronze plans. While some individuals may switch plans, others may leave the marketplace entirely, especially younger, healthier enrollees who feel less urgency to maintain coverage when the price no longer fits their budget.
The 26% figure is a national average, but in counties with strong insurer competition and lower provider costs, increases are smaller. In rural areas or states where a single carrier dominates the exchange, some consumers face hikes well above the average, compounding the subsidy loss.
What regulators and lawmakers are doing
The Department of Health and Human Services finalized its Notice of Benefit and Payment Parameters for 2026, which adjusts marketplace mechanics like user fees on the federal platform, actuarial value calculators, and the risk adjustment framework that redistributes money among insurers based on enrollee health status. These tools can nudge how premiums are set, but they operate at the margins. None was designed to offset a double-digit spike in rates driven by underlying medical costs.
On Capitol Hill, bipartisan groups in both chambers introduced legislation in early 2026 to restore or extend the enhanced premium tax credits. The proposals face uncertain prospects in a Congress consumed by broader budget negotiations. If credits are retroactively restored later this year, then enrollees could see refunds or adjusted monthly payments, but as of April 2026, the timing and scope remain unclear.
What consumers can do right now
People facing unaffordable premiums have limited but decent options. Checking whether a qualifying life event, such as a change in income or household size, opens a special enrollment period can allow a plan switch outside the normal window. Consumers who experienced a significant income drop in 2026 may qualify for larger standard subsidies than their initial application reflected. Additionally, state-based marketplaces in some cases offer additional local subsidies or lower-cost plan options not available on the federal exchange.
For those considering dropping coverage altogether, the trade-off is stark. Going uninsured eliminates the monthly premium but exposes a household to the full cost of any unexpected medical event, and there is no longer a federal tax penalty for being uninsured to weigh against that risk. Short-term health plans, which are available in many states, carry lower premiums but typically exclude pre-existing conditions and do not cover essential health benefits required of ACA plans.
Whether the marketplace can absorb the shock without a coverage spiral
Health policy researchers are watching for early signs of what actuaries call adverse selection: the cycle in which healthier, cost-conscious consumers drop coverage, the remaining risk pool skews sicker and more expensive, and insurers raise rates again the following year to cover higher average claims. That feedback loop nearly destabilized several state marketplaces in 2017 and 2018 before enhanced subsidies and insurer re-entry steadied the exchanges.
CMS enrollment figures capture sign-ups during open enrollment but do not project how many people will stop paying premiums and lose coverage mid-year. The first reliable attrition data likely will not surface until late 2026 effectuated enrollment reports become available. Until then, the marketplace sits in a precarious spot: near-record participation coinciding with the steepest increase in premiums in eight years, with no federal policy response locked in to soften the landing.
