The 2026 enrollment period for Affordable Care Act (ACA) marketplace plans ended without an agreement on the federal subsidies that have helped provide coverage to millions of Americans. Even following a last attempt in the House to extend these ACA subsidies, it became increasingly likely that Americans who rely on them would face a sharp increase in health care costs in 2026 after Congress adjourned for the year on December 19.
The debate over who should finance health care in the U.S., whether the government, individuals, or employers, has a long history. Since the passage of Medicare and Medicaid in 1965, the ACA of 2010 has been the most significant health care legislation and has remained a focal point of political contention. The law’s even helped lead to a historic 43-day government shutdown that began on 1 October 2025, pointing to the divisive nature of health policy.
Prior to the ACA, approximately 49 million Americans, or approximately 15% of the population, were not covered with health insurance, which increased to an even greater number following the 2008 recession. Because many adults aged between 18 and 64 obtain health insurance through their employers, job loss often results in loss of coverage. The ACA was supposed to decrease the number of uninsured to about 30 million people, or about 3% of the population.
However, the ACA has fallen short of these goals by half, leaving approximately 26 million Americans, or 8% of the population, uninsured today. Key provisions of the law included allowing young adults to remain on their parents’ insurance until age 26, expanding Medicaid, and offering subsidized coverage through the health insurance marketplaces. The expansion of Medicaid, which was originally intended to be mandatory but made optional following a Supreme Court decision, has been adopted by 40 states and Washington, D.C., as of December 2025, covering about 20 million Americans.
Marketplace subsidies were designed to assist low- and middle-income workers who are not offered insurance by their employers. Under the initial provision, a recipient’s income of $18,000 a year or more could pay 2.1% of the cost of their plan, while those earning $60,240 per year (400% of the federal poverty level) paid about 10%. Individuals with incomes above that threshold were ineligible for subsidies.
In 2021, temporary pandemic-era legislation expanded these subsidies by eliminating premiums for the lowest-income individuals, reducing costs for middle-income earners, and extending assistance to those earning above 400% of the federal poverty level. These enhanced subsidies are scheduled to expire in 2025. In their absence, the person who has an income of 45,000 a month would have to pay a 360 a month premium, which was an increase of 74% or 153 more a month. This increase comes on top of a projected 18% rise in insurance plan costs in 2026, which could more than double expenses for many marketplace enrollees and potentially push 5 million Americans out of coverage next year.
Opponents of the subsidies argue that the program has significantly increased federal spending, and the number of recipients grew from 9.2 million in 2020 to almost 22 million in 2025, representing a 137% increase. Critics also contend that the ACA allows employers to avoid providing coverage obligations; for example, while 92% of employers with 25 to 49 employees offered health insurance in 2010, this proportion is projected to decline to 64% by 2025.
As the country with the world’s most expensive health care system, the United States risks even higher costs if more individuals remain uninsured, as untreated illnesses often lead to more complex and expensive medical interventions.
Coverage gaps vary widely by state, ranging from approximately 3% uninsured in Massachusetts to 18.6% in Texas. These disparities reflect ongoing partisan divisions over the appropriate balance between government responsibility and individual responsibility in health care financing. Without consensus on who should bear the cost of health care, U.S. health policy is unlikely to stabilize, leaving many Americans facing uncertainty and rising medical bills year after year.
Reference: Applebaum R. As millions of Americans face a steep rise in health insurance costs, lawmakers continue a century-long battle over who should pay for health care. The Conversation. Published December 19, 2025. Accessed December 22, 2025. As millions of Americans face a steep rise in health insurance costs, lawmakers continue a century-long battle over who should pay for health care
