ACA sign-ups open Sunday with steeper premiums and tighter rules

The Affordable Care Act's marketplace window opens Sunday in most states and stays open through Jan. 15 — and this year's sign-up season comes with a price tag. Health policy researchers at KFF, analyzing fresh CMS data, expect the average cost of marketplace coverage to climb 13%. That's a spike, not a blip.

The whacks come from several directions: financial assistance is expiring, rates are climbing, brokers may be slower to answer, immigrants face new restrictions on tax credits, and enrollment checks are getting stricter. Premium tax credits and cost-sharing reductions that many people once counted on are now off-limits for several groups who used to qualify. Cynthia Cox, who runs KFF's ACA program, pins the hike mostly on rising healthcare costs and hospital market concentration, with possible pushes from the No Surprises Act and the boom in GLP-1 drugs.

The sharpest pain lands on people who don't qualify for a subsidy. "They may or may not be able to afford to continue to keep their coverage into next year," Cox said, noting many have already traded down to bronze plans, the cheapest tier. The Centers for Medicare & Medicaid Services pushed back Friday with a fact sheet saying "Americans using HealthCare.gov will have robust access to low-cost plans."

It's been a rough stretch for the exchanges. Republicans balked at extending COVID-era subsidies, and 1.2 million fewer people signed up for coverage. As of February, about 19.2 million people were actively enrolled in ACA marketplace plans, according to the Department of Health and Human Services. Enrollment had ballooned during the pandemic, when enhanced subsidies arrived via the American Rescue Plan Act and the Inflation Reduction Act.

The Trump administration is also pruning the rolls. In September, Vice President JD Vance and other officials announced plans to boot 760,000 enrollees from public exchanges, claiming they enrolled fraudulently or didn't exist at all. Vance said the move, part of a broader fraud crackdown, would save $2.2 billion. Meanwhile, regulations starting in 2027 will limit tax credits for certain lawfully present immigrants — a change that could leave an additional 1 million people uninsured over time.

Cox isn't sure how many more people will fall out of ACA coverage, but she sees the direction. With higher premiums, immigration eligibility changes and the anti-fraud push all stacking up, she said, "I think there's going to be fewer people enrolled in this market, but it's going to be harder to understand why."