ACA in 2025–26: The Coming Changes to Affordable Care Act Subsidies, Marketplace Rules, and Coverage

The Affordable Care Act (ACA) remains the foundation of the U.S. individual health insurance market—but in 2025–26, several regulatory and legislative shifts could significantly change how Americans access and pay for coverage. Rising premiums, new eligibility rules, and uncertainty around federal subsidies may impact millions of consumers and employers.

At DecipheredHealth, we break down what’s changing, why it matters, and what you should watch as the next enrollment cycle approaches.

Why the ACA Is Changing Now

The ACA has always evolved through a mix of legislation, budget rules, and administrative regulations. But 2025–26 is shaping up to be one of the most consequential transition periods since the ACA launched—driven by:

The scheduled expiration of enhanced premium tax credits created during the pandemic.
New CMS rules that tighten marketplace eligibility and enforcement.
Legislative proposals that could restructure subsidies or shift them into health savings accounts.
State-level responses that vary widely, creating substantial differences in consumer impact.

These changes could increase premiums, reduce enrollment, and reshape the role of ACA marketplaces across the country.

1. The Biggest Issue: Enhanced Subsidies May Expire in 2025

The enhanced premium tax credits (PTCs)—expanded under the American Rescue Plan Act and extended by the Inflation Reduction Act—are set to expire at the end of 2025 unless Congress takes action.

If these subsidies lapse:

Average annual premiums could more than double for subsidized enrollees.
Middle-income individuals who gained subsidy eligibility (400%+ FPL) would likely lose access.
Enrollment could drop sharply, especially among lower-income consumers.

The Kaiser Family Foundation estimates that benchmark plan net premiums could jump from ~$888 to nearly $2,000 per year for a typical marketplace enrollee without renewed subsidies.

2. New CMS Marketplace Rules Tighten Eligibility & Premium Enforcement

A major regulatory package—the 2025 Marketplace Integrity and Affordability Final Rule—introduces changes beginning as early as August 2025.

Key changes include:

✔ Stricter Eligibility Verification

More documentation will be required during enrollment and renewal phases, increasing the risk of consumers losing coverage due to incomplete paperwork.

✔ Insurers Can Require Payment of Past-Due Premiums

Plans may now:

Deny new coverage until both initial and past-due premiums are paid.
Prevent reinstatement unless delinquent balances are cleared.

This could create gaps in coverage for individuals who miss a payment during transitions or life events.

✔ Narrower Interpretation of Marketplace Eligibility

Advocates warn that some groups—such as certain DACA recipients—may lose marketplace access depending on how the new rules are enforced at the state level.

These regulatory decisions could increase churn and reduce overall enrollment.

3. Legislative Proposals Could Reshape ACA Subsidies

Several congressional proposals would significantly change how ACA financial assistance works.

🔹 Expand Subsidies

The Health Care Affordability Act of 2025 (H.R. 247) seeks to remove the 400% FPL cap entirely, making subsidies available to more middle-income households.

🔹 Replace ACA Credits With HSA Contributions

Other plans propose routing government assistance into Health Savings Accounts, shifting consumers toward high-deductible, more “consumer-directed” plans.

🔹 Budget Reconciliation Impacts

Broader federal budget discussions include proposals that may:

Reduce Medicaid spending
Change marketplace eligibility
Alter federal support for ACA exchanges

These policies could indirectly reshape the ACA’s structure.

4. State-by-State Differences Will Widen

States play a critical role in ACA marketplace implementation. Key differences include:

Some states may introduce supplemental subsidies (e.g., California-style affordability support).
Others may have limited capacity, leading to higher dropout rates.
States with strong navigator programs and outreach may better retain enrollees under the new rules.

Expect larger variation in premiums, plan availability, and consumer experience based on where you live.

📉 What These Changes Mean for Individuals and Families

If subsidies expire, expect:

Higher monthly premiums
Reduced plan choice
More people shifting to catastrophic or short-term health plans
Increased uninsured rates

Under the new CMS rules, expect:

More documentation requests during enrollment
Denials if past-due premiums exist
Increased complexity when switching plans

Bottom line:

Consumers should prepare now—costs may rise, and the enrollment process may become more complicated.

🏢 What Employers and Providers Should Watch

Employers:

Employee shifts between marketplace and employer-sponsored plans may increase.
Rising individual market premiums may affect recruiting and retention.
Added complexity may spur demand for brokers and benefits advisors.

Providers:

Increased uninsured rates could reduce reimbursement stability.
Coverage churn may disrupt continuity of care.
Facilities may need stronger eligibility-verification workflows to prevent claim denials.

📝 What You Can Do Now

Whether you’re a consumer, a provider, or an employer, here’s how to prepare:

Review your 2025 marketplace plan early and budget for potential 2026 premium increases.
Monitor federal updates on subsidy extension bills.
Expect more paperwork—keep documentation ready at renewal.
Check your state’s marketplace initiatives, as some may add consumer protections.
If you’re an employer, plan internal communication around potential subsidy changes.

The ACA is entering one of the most dramatic periods of change since its creation. The combination of subsidy uncertainty, new regulatory rules, and shifting legislative priorities means 2026 could look very different for health coverage in America.

At Deciphered Health, we’ll continue to monitor policy developments and publish practical breakdowns to help you stay informed—without the political noise.