When open enrollment ended earlier this year, 23.1 million Americans had signed up for health coverage through the Affordable Care Act marketplace, 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 may have paid around $100 a month after enhanced federal subsidies. Based on examples in a CMS pricing fact sheet, that same plan in 2026 runs closer to $400.
Nationally, average benchmark premiums climbed 26% this year, the steepest single-year jump since 2018, when silver-plan rates spiked roughly 34% after insurers lost federal cost-sharing reduction payments. This time, the cause is different but the sticker shock is familiar.
Why premiums surged
Two things happened at once. The enhanced premium tax credits, first 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, and 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 is real, documented in insurer rate filings and independent analyses, but a precise federal accounting does not yet exist.
Who feels it most
The increase 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. The group most exposed 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, the answer is downgrading. Silver-tier plans pair moderate premiums with lower deductibles, but bronze plans carry cheaper monthly payments, even if deductibles top $7,000. 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.
Geography sharpens the divide. The 26% figure is a national average. 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 rate spike 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, enrollees could see refunds or adjusted monthly payments, but as of May 2026, the timing and scope remain unclear.
What consumers can do right now
People facing unaffordable premiums have limited but real 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. 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. Until then, the marketplace sits in a precarious spot: near-record participation running headlong into the steepest rate increase in eight years, with no federal policy response locked in to soften the landing.
