Physician assistant Ambar Solis-Fuentes examines Mariana Reyes Velazquez at Tepeyac Community Health Center in Denver in July 2025. Such centers play an important role in serving people who lack insurance, numbers of which may be growing.
Photo by Hyoung Chang, courtesy Denver Post/Getty Images
Two years ago, Tom and Carol Shaw of Lewisberry, Pennsylvania, bought a gold-level health insurance plan on the state's health insurance marketplace. The 2025 plan had no deductible and a premium of $1,095 a month after an enhanced tax subsidy discount.
At the end of the year, the couple received a renewal letter from the state-based exchange saying their monthly premium would jump to $3,505, a 221% increase, catching the couple off guard.
“I couldn't believe how much it went up,” Carol Shaw, 63, told The Nation's Health.
Costs of insurance plans sold through Affordable Care Act marketplaces have skyrocketed, increasing on average 26% this year, according to a July report from the Centers for Medicare and Medicaid Services. Both HealthCare.gov plans and state-based exchanges saw double-digit increases.
An estimated 5 million consumers are expected to drop their coverage, which would plunge marketplace enrollment from 22 million to 17 million, KFF said.
Among wealthy countries, the U.S. is one of the worst for health insurance affordability and has an 8% uninsurance rate, a spring Commonwealth Fund report said. Experts say millions more Americans have become uninsured this year due to economic inflation, changes to Medicaid and the rising cost of health insurance premiums.
Loss of marketplace subsidies have been a driver of the crisis. In January, Congress allowed the Biden-era tax-credit subsidies to expire. Premiums doubled or tripled for some customers on the marketplace. By February, 2.6 million people had dropped their plan, according to federal data.
U.S. uninsured rates for this year were not available as of July, but health centers and hospitals are reporting more uncovered patients, fresh off marketplace rolls.
Sheila Kennedy, DNP, MPH, CNM, medical director at Southside Community Health Services in South Minneapolis, said patients come in every day who lost coverage on MNsure, the state-based exchange.
“It's unbelievable the amount of patients we are seeing, a lot of families,” Kennedy told The Nation's Health. “They earn too much to qualify for Medicaid, but they don't have insurance through their job.”
Southside Community Health predominantly cares for patients who are uninsured. Former exchange users are often seen for chronic conditions and prescription medications, Kennedy said. As a federally qualified health center, the center's pharmacy sells medicines at substantial discounts through the federal 340B Drug Pricing Program. But federal paperwork slows the process.
“Patients are going weeks or months without their medications, simply because of the administrative burden,” she said.
In Pennsylvania, 2026 open enrollment in Pennie, the state's health insurance marketplace, declined 12% to 486,000 participants, as most premiums doubled in cost. That was followed by over 87,400 enrollees, or 18%, dropping their plan in January.
Family First Health runs 10 federally qualified health centers in south central Pennsylvania. About half of patients are covered by Medicaid and 11% are uninsured.
Jenny Englerth, president and CEO of Family First, said she has seen an uptick of uninsured patients who previously had a marketplace plan.
Recently, an adjunct professor at a local university who did not have employer-based health insurance visited a Family First clinic. His chronic health condition had worsened over the last year, Englerth said. The patient, who was nearing retirement age, said he did not want to go to an in-network clinic on his Pennie plan because of high out-of-pocket costs.
“We are seeing people every day who are making choices between rent and food, putting gas in their cars and prescriptions, or getting preventative care for their children,” Englerth told The Nation's Health.
Of the 20 Pennsylvania counties with the highest disenrollment relative to population, 15 were rural counties.
“A significant population of rural residents are self-employed, seasonally employed or employed in a small business and don't have the access to employer-sponsored coverage, as people do in urban or suburban areas,” Carrie Cochran-McClain, DrPH, chief policy officer at the National Rural Health Association, told The Nation's Health.
About 33,000 enrollees to Pennie this year switched to bronze-level plans, a 30% jump compared to 2025. The tier offers lower premiums, less coverage, higher deductibles and other out-of-pocket costs.
After receiving their Pennie renewal letter, the Shaws switched to a bronze plan for 2026. Their premium dropped to $2,866 a month, but with a $7,450 deductible for each of them.
In February, Tom Shaw, 64, was hospitalized for a serious blood condition, followed by eight weeks of IV-administered antibiotics. He reached his deductible within days. Carol Shaw is a stroke survivor and depends on prescription medicines, which the insurance company covered only after her deductible was reached.
The Shaws said they have spent nearly $50,000 out-of-pocket on medical bills since switching to the bronze plan. Unfortunately, it may not be getting better for consumers. Marketplace customers can expect another round of double-digit premium increases in January. Affordable Care Act insurers have asked state regulators for a median rate increase of 14% for 2027.
“With the wealth we have in this country, it's ridiculous to think we cannot make healthcare more affordable for everybody who lives here,” Tom Shaw said.
Meanwhile, uncompensated care at hospitals and health clinics due to more uninsured patients and cuts to Medicaid reimbursement under a 2025 federal budget bill are expected to cause a crisis at healthcare systems as provisions go into effect.
“It's really a double whammy of hospitals losing some of their current reimbursement, then seeing a greater percentage of patients who have no insurance,” Beth Feldpush, DrPH, senior vice president of policy and advocacy at America's Essential Hospitals, told The Nation's Health.
Federally qualified health centers, a lifeline for the uninsured, are also in trouble. Federal funding is being cut as demand for their services rise.
“There is a concern about how we will be prepared to continue to handle additional influx of new patients and patients coming with different situations and different circumstances,” Englerth said.
Family First is beefing up its healthcare navigators to help patients with coverage and payment questions, she said. The centers are also expanding pharmacies and telehealth services.
“We're doing everything we can to continue to enhance the primary care model in a way that addresses access and cost,” Englerth said.
For more on rising health insurance costs, visit www.kff.org.
- Copyright The Nation’s Health, American Public Health Association
