It’s over. After 43 days, the longest government shutdown in history has come to an end with a plan to keep the government open until January 30, 2026. But it ends without a fix for the millions of Americans who rely on premium tax credits (PTCs) to buy Marketplace health insurance coverage. While Congress has agreed to take up a vote on PTCs in December, premiums are currently on course to more than double next year.
But even if Congress takes last-minute action to extend PTCs, high premium prices during the opening weeks of Marketplace Open Enrollment have already driven some consumers to walk away from coverage for 2026. Moreover, separate policies under the so-called “One Big Beautiful Bill Act” and recent regulatory changes will reduce access to coverage and care for immigrants and people who use gender affirming care. And as affordable, comprehensive coverage slips out of reach, individuals shopping for coverage may be confronted with an array of bewildering options ranging from catastrophic plans to junk insurance.
Skyrocketing Premium Costs Will Drive People Out of the Marketplace
Without Congressional action, consumers will see an average 114% increase in out-of-pocket premiums in 2026. This is a result of two factors: reduced PTCs and increased underlying premiums. Aware that PTCs were set to drop, and mindful of the impacts of inflation, tariffs and other federal changes under OBBBA recent regulations, insurers anticipated that higher prices would discourage healthier people from enrolling in Marketplace coverage. This leaves a smaller, less stable risk pool with higher premiums for those who remain covered.
People with very low incomes (under 150% of the Federal Poverty Level (FPL)) have been eligible for $0 silver plan premiums in recent years, but will lose access to such plans in 2026, imperiling their access to coverage. Middle income households over a 400% cutoff will lose all PTCs. And older people, whose premiums can be up to 3 times higher than their younger counterparts, will be among the hardest hit. As a result, CBPP calculated that a 60-year old couple in West Virginia making a combined $85,000 per year would see their monthly premiums go from an already costly $602 a month to more than $4,500 a month.
According to the Congressional Budget Office, close to 4 million people will ultimately become uninsured if Congress chooses to allow PTCs to return to pre-2021 levels permanently. But even if a compromise is cobbled together before the end of the year, a widely-reported CBO estimate found that waiting until the end of the year to extend PTCs will drive 1.5 million more people to become uninsured in 2026.
Lawfully Present Immigrants Will Lose Access to Affordable Care
In addition to increased premium costs, regulatory and statutory changes will reduce immigrant access to coverage. Despite incendiary and dishonest rhetoric to the contrary, undocumented people have never been eligible to enroll in Marketplace coverage, with or without PTCs. But recent policy changes will take coverage away from many lawfully present non-citizens. In August 2025, the Centers for Medicare & Medicaid Services (CMS) rescinded Marketplace coverage for DACA recipients. On January 1, 2026, lawfully present people with incomes below 100% FPL who are not eligible for Medicaid due to their immigration status (for example, because of the so-called “five-year bar”) will be prohibited from receiving PTCs, effectively eliminating their access to affordable coverage. CMS has announced that these enrollees will be automatically re-enrolled into plans at full cost next year unless they take action to change or drop coverage. This change previews even broader immigration restrictions from OBBBA that will go into effect in 2027, when all lawfully present non-citizens other than green card holders, Cuban/Haitian entrants, and COFA migrants will lose access to PTCs.
Administrative Actions Aim to Reduce Access to Gender Affirming Care
Additionally, CMS’s recent Marketplace Final Rule excludes so-called “sex-trait modification” from coverage as an Essential Health Benefit (EHB), effective in 2026. This change is intended to make such health services more expensive and less accessible when used to treat gender dysphoria. The policy, which has no basis in science or medicine, is intended to reduce access to gender-affirming care by increasing consumer out of pocket costs to access such services as well as the administrative burden on plans that continue to offer coverage for them.
Junk Insurance and High Deductible Plans Offer a Disturbing Preview of “TrumpCare”
Alternatives to PTC extension leave much to be desired. As Congress weakens access to affordable, comprehensive coverage by allowing enhanced PTCs to expire and curtailing coverage under OBBBA, the administration is clearing the way for junk plans that are designed to maximize industry profits and minimize coverage. In September, CMS responded to the looming expiration of PTCs by expanding eligibility for high-deductible catastrophic health plans which cannot be purchased with PTCs and risk siphoning healthy people from the individual market, pushing premiums even higher over time. Meanwhile, President Trump and some Members of Congress have chosen to inject more turmoil into a chaotic Open Enrollment period by teasing half-baked proposals to re-route PTCs to various tax-advantaged accounts that would benefit the wealthy and leave average consumers unprotected.
So what’s next for consumers staring down the December 15 deadline to enroll in January 1 coverage?
While a deal may still come together, the window for Congress to act is closing fast. Open Enrollment has always been a key opportunity for consumers to engage with their coverage options and make necessary changes, but doing so this year is imperative. Households are likely to be weighing an array of unappealing choices: paying higher premiums, shifting to a lower-level plan with higher cost-sharing amounts, or even dropping coverage entirely. Many will be targeted by misleading marketing for junk insurance designed to look like the real thing. To avoid being caught by surprise with an unexpectedly high bill or automatic bank draft for coverage that is no longer affordable, individuals should examine their coverage options now, consider opting out of automatic re-enrollment, and work with a local Navigator or assister to put together a game plan for next year.
