What to know as the Affordable Care Act open enrollment window gets underway

People enrolling in Affordable Care Act coverage should prepare for higher premiums and fewer plan choices

WASHINGTON — People entering the Affordable Care Act open enrollment period with plans to buy insurance should expect several changes, including higher premiums and fewer coverage options.

The marketplace sign-up period, also called Obamacare, begins in most states and continues through Jan. 15.

Major shifts in the exchange include expiring financial aid, rising rates, possible delays when working with a broker, new limits affecting immigrants and tighter enrollment verification.

Financial assistance, including premium tax credits and cost-sharing reductions, is now limited for many people who were previously eligible.

Overall, health policy experts expect less coverage and higher prices, with the average cost of marketplace health insurance projected to increase by 13% in 2027, according to KFF, a health research nonprofit that analyzed new CMS data.

Several forces are pushing costs higher

Cynthia Cox, a vice president and director of KFF's ACA program, said the increase is being driven mainly by rising medical costs, hospital consolidation and possible influences such as the No Surprises Act, which began in 2022 and bars surprise billing, as well as the growing use of GLP-1 drugs.

People who do not qualify for subsidies are likely to feel the biggest impact.

“They may or may not be able to afford to continue to keep their coverage into next year,” Cox said, adding that “a lot of them have already moved into bronze plans, which are the cheapest plans.”

A CMS fact sheet on open enrollment issued Friday says “Americans using HealthCare.gov will have robust access to low-cost plans.”

ACA premiums have climbed sharply for many people during Trump’s second term after Republicans opposed extending pandemic-era subsidies that had helped offset health insurance costs for most enrollees during Democratic President Joe Biden’s administration.

As a result, 1.2 million fewer people signed up for exchange coverage.

Nearly 20 million people are enrolled in ACA plans nationwide

By February, about 19.2 million people in the United States were actively enrolled in ACA marketplace health plans, according to the Department of Health and Human Services website. Enrollment increased during the COVID-19 pandemic when enhanced subsidies were made available through the American Rescue Plan Act and the Inflation Reduction Act, both signed into law by Biden.

New rules taking effect in 2027 will also restrict tax credits for some lawfully present immigrants, which could lead to another 1 million uninsured people over time.

At the same time, the Trump administration has been removing ACA enrollees from the program as part of its broader campaign against what it calls waste, fraud and abuse.

In September, Vice President JD Vance and other officials in the Republican administration announced plans to remove 760,000 ACA enrollees from public health exchanges, saying the people had been fraudulently enrolled or did not exist. Vance said the discovery and the cancellation of subsidy payments for hundreds of thousands of people, part of an administration-wide fraud crackdown, would save $2.2 billion. Cox said it remains unclear how many additional people will leave ACA coverage in 2027. But with higher premiums, immigration-related eligibility changes and anti-fraud efforts, “I think there’s going to be fewer people enrolled in this market, but it’s going to be harder to understand why.”