Affordable Care Act Cost Spikes Harm Older Adults

The Affordable Care Act (ACA) has helped millions of older adults obtain coverage and care. But the expiration of enhanced federal subsidies in December 2025 is threatening that progress. A KFF Health News and USA Today article, “Rising Health Costs Push Some Middle-Aged Adults To Skip the Doc Until Medicare,” examines enrollee experiences in light of the rolled-back cost assistance.

The ACA Tax Subsidies

Since 2012, ACA tax credits have helped people with low and middle incomes pay their Marketplace premiums. In 2021, the American Rescue Plan Act (ARPA) increased the amount and availability of the subsidies and the Inflation Reduction Act (IRA) in 2022 kept them in place through the end of 2025. Congress did not extend them, resulting in significant price hikes and hardships this year.

The ACA Has Helped Millions

The ACA tax credits have allowed millions of adults ages 50 to 64 buy coverage—spurring a 50% reduction in the uninsured rate among this cohort—while helping overall Marketplace enrollment grow from 12 million in 2021 to a record 24.2 million in 2025.

People with lower incomes have seen the highest gains.

People with lower incomes have seen the highest gains. As earlier KFF analysis notes, “The recent growth in ACA Marketplace plan enrollment has been driven primarily by low-income people, with signups by people with incomes up to 2.5 times poverty growing 115% since 2020.”

Older Adults at Significant Risk

The enhanced subsidies reduced enrollee premium payments by $705 a year, on average. Without this help, coverage becomes much less affordable for more than 22 million people, including many with modest incomes and older adults who are not yet Medicare-eligible.

The ACA affordability cliff is steep. In 2026, Marketplace enrollees with incomes over 400% of poverty ($86,560 for a family of two in 2026) were cut off from subsidies entirely, and people with incomes between 100% ($21,640 for a family of two) and 400% of poverty began receiving less support.

Over half of all enrollees who no longer qualify for tax credits are between the ages of 50 and 64.

Older adults have been hit especially hard. Over half of all enrollees who no longer qualify for tax credits are between the ages of 50 and 64. They are facing the full costs of their premiums, which have increased by more than 20% on average, though some have seen even higher jumps. And older enrollees are already at a cost disadvantage: Under the ACA, insurers can charge people in their 50s and 60s higher premiums than they charge younger adults who purchase the same plan in the same area.

Enrollee Impacts

KFF reports that many people are seeing yearly rate increases of thousands of dollars, with premium payments totaling as much as a quarter of their incomes. With many middle-aged adults already enrolled in the lowest-cost plans available, there are few ways to cut back.

This can force impossible choices. KFF spoke with a primary care physician whose older patients are struggling to afford ACA coverage, with some going uninsured as a result. They also heard from enrollees themselves, including a 63-year-old social services worker whose monthly premiums more than doubled. Coupled with a $10,150 out-of-pocket maximum, she is weighing whether the costs are worth it. Some who keep coverage are looking for savings elsewhere. With few levers to pull, this may mean delaying needed care until they become Medicare-eligible. In Rhode Island, a 64-year-old retiree decided to forgo a colonoscopy after his 2026 ACA premiums more than tripled. Those costs now eat up a third of his income, and his $3,000 deductible is another affordability barrier. He expects to spend $30,000 in retirement savings to maintain ACA coverage until he qualifies for Medicare.

He expects to spend $30,000 in retirement savings to maintain ACA coverage until he qualifies for Medicare.

Short-Term Savings, Long-Term Costs

Dropping coverage or delaying care until age 65 may save enrollees money now, but the tradeoffs may end up being more costly. Such strategies put their physical health at risk, and can raise costs over the long-term—for the individual, Medicare, and taxpayers—as health issues worsen amid the delays.

Affordability Concerns Compounded

The rising costs of ACA coverage are adding to existing concerns about health and economic security, and they are putting additional financial pressure on older adults.

Even before the subsidies expired, older adults were facing difficult headwinds. A 2024 AARP survey found that one in five adults over 50 had no retirement savings and three in five were worried they wouldn’t have enough retirement savings to support themselves. A University of Michigan survey that year found “the costs of medical care, nursing homes, and prescription drugs were among the top health-related concerns for people over 50.”

March 2026 KFF polling of ACA marketplace enrollees confirms health care costs are straining household budgets, leading to impossible choices:

Among 2025 Marketplace enrollees who have re-enrolled in Marketplace coverage, many report that their health care costs are putting pressure on household budgets. A majority (55%) of returning Marketplace enrollees say they are (or will be) cutting back spending on food or basic household items in order to afford the costs of coverage and care. The impact is even harder for returning enrollees with chronic health conditions, with 62% saying they are, or will be, cutting back on food and other household items in order to help them afford their health care costs.

Congressional Action Needed

A previous AARP report found nearly all (92%) of the 5.2 million adults ages 50 to 64 with Marketplace coverage would experience higher costs this year due to the subsidy expiration.

While some may be able to find other insurance, millions will not. The resulting coverage losses will mean reduced access to care and worse individual health outcomes as well as higher Medicare costs, because more people would enter the program in poorer health and needing more expensive interventions than they would have otherwise.

Across all age groups, at least 4.2 million people are expected to become uninsured unless Congress acts to reinstate this critical cost assistance.

Medicare Rights continues to urge lawmakers to do so without delay. The health and economic security of millions of Americans hangs in the balance.