In January, when President Trump unveiled his one-page outline to address healthcare spending, dubbed the “Great Healthcare Plan,” he specifically mentioned the Affordable Care Act’s role in driving up costs.
“I call it the unaffordable care act,” he said. He reprised the line in his 2026 State of the Union address, blaming “the crushing cost of healthcare” on Obamacare.
Trump’s words also play off a congressional debate that began late last year with the expiration of the enhanced tax subsidies that had lowered the cost of ACA insurance for millions of Americans — and thrust the issue of ACA-related costs back to center stage.
Without those enhanced subsidies, the amount people pay toward monthly Obamacare premiums doubled, on average. So far, the number of people enrolled in ACA coverage for this year has dropped by more than a million, and experts say more people could abandon coverage once premiums come due. Democrats are using this development to crank up the heat on Republicans ahead of the November elections and steer the conversation on the affordability issue.
Republicans fault the law itself for driving up these costs. For instance, Rep. Mike Lawler (R-N.Y.) has said that premiums “skyrocketed across the country since it took effect.”
Critics routinely point to several provisions within the ACA as the culprits — among them, essential health benefits, or EHBs. Under the law, Obamacare plans must cover certain essential services, including emergency care, hospitalization, maternity and prescription drugs, without annual or lifetime dollar limits. But connecting EHBs to the premium increases felt by consumers is not straightforward.
Here’s a primer on key issues involved:
Checking the numbers
It’s clear that Obamacare premiums have increased.
An analysis by the right-leaning Paragon Health Institute shows that the average premium for a 50-year-old with Obamacare grew by 129% since 2014. The average premium for employer-based plans grew 68% during that same time.
Paragon’s president, Brian Blase, told KFF Health News that this shows the ACA has made healthcare on the individual market more expensive.
Still, the comparison overlooks a couple of points. Pre-ACA, employer plans generally offered more generous coverage than individual market plans, so work-based coverage cost more. And individual plans were cheaper in part because they could bar applicants with health problems. Beginning in 2014, the ACA forced individual policies to look more like employer plans, covering a broader range of benefits and accepting both healthy and unhealthy applicants. As a result, premiums rose that first year. In the years that followed, ACA plans often experienced faster growth in premiums than job-based plans. Some policy analysts say this isn’t surprising because ACA plans started at a lower dollar base and had more room to rise.
States that saw less dramatic post-ACA premium increases, such as Massachusetts and New York, already mandated that individual-market plans provide EHB-like coverage, noted Edmund Haislmaier, a senior research fellow at the Heritage Foundation, a conservative think tank. These states also had higher premiums due to that and other provisions, such as not allowing plans to exclude people with preexisting conditions.
“It was a combination of things,” he said.
Blase acknowledges that the two types of insurance started at different price points. But he said the percentage change over time shows that the ACA faces “underlying inflationary pressures” — including the now-expired, more generous, covid pandemic-era subsidies — that affect its policyholders more so than employer plans.
Aside from that point, however, premiums on the individual insurance market were on the rise even before the ACA took effect.
An analysis by MIT’s Jonathan Gruber found that between 2008 and 2010, premiums grew by at least 10% a year and were highly variable across states and insurers.
Consumers’ other costs
Over time, ACA deductibles — the amounts policyholders must satisfy in a given year before insurance kicks in — have seen large increases, with “bronze” plans now averaging $7,476 annually, up from $5,113 in 2014, according to KFF, a health information nonprofit that includes KFF Health News. Bronze plans tend to have lower premiums than the other metal-level categories — silver, gold, and platinum — in part because of their higher deductibles.
The Trump administration is doubling down on high-deductible plans as part of its emphasis on affordability, making it easier this year for people age 30 and up to qualify for what are called “catastrophic plans.” These come with even larger deductibles than bronze plans.
The administration pitched a broad regulatory plan for 2027 to cement those changes, saying it was designed to lower premiums and expand choices. It would raise next year’s deductibles for catastrophic plans to $15,600 a year for an individual or around $30,000 for a family. It isn’t clear how popular such plans would be. Detailed enrollment figures for this year are not yet available, but estimates indicate only about 54,000 people chose catastrophic plans in 2025, and consumers can’t use federal subsidies to purchase them.
Before this Trump proposal, though, recent data showed that the rising rate of ACA plan deductibles had not outpaced deductibles for employer plans.
The weighted average — a calculation that gives more weight to ACA plans with the most people enrolled — shows about a 55% increase in annual deductible amounts since 2014, from $1,881 to $2,912. During that same period, deductibles in plans offered by employers rose on average 59%, from $1,186 to $1,886, according to KFF’s annual employer survey.
Essential what?
To be clear, the ACA’s catastrophic and bronze plans must cover essential health benefits, as do all Obamacare plans. These EHBs fall into 10 categories of medical services and were included in the ACA to ensure individual policies meet a minimum standard of coverage and are comparable to employer-based health insurance.
Preventive services, such as annual checkups, vaccines, and certain cancer screenings, must be covered at no additional cost to patients. All plans must completely cover the cost of specific vaccines, including the annual flu shot. And insurers cannot refuse to pay for emergency care provided at an out-of-network hospital. Other EHBs are subject to out-of-pocket costs, such as copays at the doctor’s office or pharmacy counter.
In some ways, EHBs save money because they’ve increased access to preventive care, said Gerard Anderson, a professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health.
Services such as cancer screenings and lab tests can lead to earlier detection of serious conditions, when treatment is less costly, and positive outcomes are more likely.
“If you look down the list of essential health benefits, I think most people would reach the judgment that those are health care services that people should have access to,” said Larry Levitt, KFF’s executive vice president for health policy.
Joseph Antos, a senior fellow emeritus at the conservative American Enterprise Institute, said ACA requirements — such as requiring insurers to accept anyone, regardless of their health status, and limiting insurers’ ability to charge older people more for coverage — also have played roles in boosting premiums.
“Really, it’s practically impossible to tease any one thing out,” Antos said.
States do have latitude to add benefits that fall under the EHB umbrella. For example, bariatric surgery is covered as an EHB in West Virginia, but not in Pennsylvania. Pennsylvania’s EHBs also don’t include hearing aids, but New Jersey’s do.
But the Trump administration’s 2027 regulatory proposal doesn’t cast this flexibility in a positive light: When “states enact benefit mandates, plan premiums must generally increase to account for the additional coverage,” it reads. It also signals that added benefits can raise consumer costs and proposes that states be required to use their own funds to offset some of those costs.
Paragon’s Blase echoed this take in his bottom line. Mandating that plans cover EHBs without annual or lifetime caps, as required under the ACA law, encourages clinicians to overbill and overprescribe, he said. That drives up premiums and means a bigger check for insurers and medical providers at the expense of taxpayers. “You just turn patients into money factories,” he said.
Stacey Pogue, a senior research fellow at Georgetown University’s Center on Health Insurance Reforms, disagrees, saying that whatever EHBs’ role, they aren’t to blame for the year-over-year premium hikes.
People aren’t consuming medical care at exponential rates just because certain services are now covered: “Me not paying anything for that colonoscopy doesn’t make me want to get more of them,” she said.
Appleby and Boden write for KFF Health News, a national newsroom that produces in-depth journalism about health issues.
