Some nights Rachel Phipps bolts up in bed, worried about what might happen if she gets sick.
Phipps, of Kennebunk, Maine, has precancerous cells on her face that require treatment. She has been coughing for months for reasons that aren’t clear. And she has been advised to get an RSV vaccine. But she no longer has health insurance, so she’s paying out of pocket for her dermatology care while skipping the vaccine and the chest X-ray her doctor ordered.
“It’s terrifying,” she said. “To be 64 years old and wake up with no insurance is insane.”
The expiration of enhanced Affordable Care Act (ACA) health plan subsidies is now playing out across the country and older adults are getting hit especially hard, according to a recent report by KFF. Preliminary data from several state-based exchanges suggest the problem is most acute in rural areas, where coverage has always cost more and access to care is already limited.
Some 8 million people ages 50 to 64 were insured last year through the ACA marketplace. They represent one-third of all enrollees. But older adults make up roughly half of marketplace consumers who are no longer eligible for any federal assistance because they have incomes above the new cutoff. That’s 400% of the federal poverty level, or $63,840 a year for an individual.
The loss of enhanced subsidies was just the first blow. Insurers quickly imposed the biggest price hike for ACA plans in eight years. In part, that’s because insurance companies projected that their most profitable customers — healthier people — would cancel coverage without federal support, according to the KFF report.
People earning less than 400% of the poverty level still qualify for federal tax credits but the subsidy amounts are lower than they would have been if the enhanced subsidies hadn’t lapsed.
People of all ages, including many who are barely making ends meet, have seen their premiums and out-of-pocket costs spike. But federal rules allow insurers to charge older adults up to three times more for coverage than younger people. So while premiums have increased 114% on average, they have tripled and even quadrupled for many people in their 50s and 60s, according to KFF.
It’s not surprising, then, that in Pennsylvania, for example, 55- to 64-year-olds dropped marketplace coverage this year at higher rates than any other age group. Fifteen of the 20 counties that had the highest rates of terminations were rural.
Overall, 18% of marketplace consumers in Pennsylvania dropped their insurance.
Many people who kept coverage, older adults especially, switched to a skimpier plan with lower premiums (though often higher than the cost of a more generous plan last year) and significantly higher deductibles and out-of-pocket costs (up to $10,600 for an individual).
The pressure to downgrade insurance like this will almost certainly discourage a lot of working-class people from getting care until the need is dire.
Maine is one of the most rural states, and people insured through the marketplace skew older than the national average. The state had record-high enrollment in ACA plans in 2025. This year, participation fell to the lowest levels since Maine launched its state-based marketplace in late 2021.
Like Rachel Phipps, roughly one-third of those who canceled coverage in Maine said they could no longer afford it.
She and her husband, a self-employed woodworker, signed up for a marketplace plan last year, after she retired from a social work job to care for her ailing mother and no longer had insurance through work.
Even under the old rules — which allowed people with higher incomes to qualify for subsidies if the cost of their health plan exceeded 8.5% of their income — the marketplace coverage was expensive. Phipps said the couple spent more than $10,000 on premiums, deductibles and copays last year.
This year, Phipps said, they would have to pay $2,864 a month for premiums and an annual deductible of $7,500 each. “We were looking at potentially spending more than $49,000 for 2026,” she said. “That would have been 46% of our income.”
She recently took a part-time job in a preschool for children with autism. She was advised to get the RSV vaccine because of potential exposure on the job and her respiratory condition. When the pharmacy said it would cost $349, she declined.
“It’s absurd,” she said. “It would be free if I had health insurance.”
Nationally, ACA marketplace enrollment has fallen by more than 1 million people this year. And that likely understates the impact of the federal government’s refusal to extend the enhanced subsidies.
People may continue to drop coverage as the grace period for unpaid premiums ends and bills come due.
Reporters can track the final tallies on enrollment and cancellations, which officials expect to have this spring. It’s especially important to look at trends and prices state by state, because they vary widely.
For example, the average unsubsidized premium for the lowest-tier plan for a 60-year-old is $20,005 in Wyoming, $8,002 in Massachusetts, and $7,215 in Maryland, according to KFF.
These last two states are among the 10 providing their own subsidies to replace at least some of the loss of federal support. The others are California, Colorado, Connecticut, New Jersey, New Mexico, New York, Vermont and Washington. The scope of these initiatives and eligibility vary. A few more states are creating similar programs or have taken up legislation to do so.
It’s not clear how long states will be able to sustain expensive efforts to backfill the expired subsidies. They’re also scrambling to make up for lost federal funds in other vital areas, including education, food assistance and housing security. Meanwhile, the Trump administration has proposed more far-reaching changes in marketplace plans for 2027 that would further drive up costs and restrict eligibility for federal assistance.
For Rachel Phipps there is one bright spot on the horizon: She’ll turn 65 next year and be eligible for Medicare. But her husband won’t hit that milestone for three more years.
“Luckily, he’s in pretty good health now,” she said. “But he’s in his 60s and doing hard labor. And he’s in a very dangerous business. God knows what will happen.”
