Marketplace Enrollees Speak Out: People Fear Higher Costs if Congress Does Not Act

As part of a law passed in 2021, Congress expanded the premium tax credit (PTC) to help make coverage more affordable for people who buy their insurance through the Affordable Care Act (ACA) marketplaces. The result has been remarkable: nearly 21 million people are receiving ACA coverage in 2024 – a record – driven by the improved and expanded PTCs. More than 9 out of 10 people with marketplace insurance use the enhanced PTCs to pay for their coverage, and the tax credit enhancements have been especially critical for increasing health insurance coverage for Black and Latino people.

Affordable health insurance has provided many people economic security, greater wellness, and peace of mind. But the clock is ticking: the expanded PTC is set to expire in 2025 if Congress does not act. Congressional inaction would be devastating: almost everyone in the marketplace will see their insurance costs spike, and an estimated 4 million people will lose insurance in the first year alone because they won’t be able to afford the premiums.

Take Erin, a 62-year-old white woman from Georgia. The improved PTC allows her to have enough money to comfortably pay ahead for electricity and other bills and still have money left over. “I can pay extra and have a little buffer instead of going from paycheck to paycheck to keep it paid,” she said. “It allows me to stock up on things and not have to just buy the bare minimum because that’s all the money I have.”

Erin works as a mental health technician and has an income of about $38,000. Her premiums would jump by about $134 per month if Congress doesn’t extend the PTC improvements. (Estimates of net premium increases throughout this piece are based on 2024 plan enrollment and premiums.) The ACA “needs to be constantly improved and tweaked to serve the people that it covers,” Erin said. “We need the tax credit.”

If Congress lets enhanced tax credit expire, enrollees would have to make impossible tradeoffs

Erin was one of 15 people in 11 states who participated in interviews in which marketplace enrollees shared what increased PTCs have meant to them and what the impact would be if Congress allows the improvements to expire at the end of 2025. The project was led by CBPP in collaboration with PerryUndem, with interviews conducted in July, August, and September 2024.

In virtually every conversation, it was evident that the possibility of significant premium increases would force marketplace enrollees to grapple with impossible trade-offs or the prospect of dropping health insurance altogether.

Dontre, a 36-year-old Black man working in the IT field and living in North Carolina, is planning with his wife to buy their first home and have their first child. He says the enhanced premium tax credit “played a significant role” in allowing him and his wife to save hundreds of dollars every year — money they would otherwise have spent on health insurance — to plan for their future. If the enhanced PTCs expire, Dontre’s premium for his family plan would increase by an estimated $120 per month, to $589, throwing a wrench in their financial plans during a time of major life milestones.

“What condition do I stop treating?”

For individuals with chronic or complex conditions who are juggling the costs of medications, specialist visits, and other services to manage their conditions, a premium increase would throw a household budget with little extra room into chaos. Going without coverage is simply not an option, many said, but having to pay a higher premium could mean making tough decisions about what care to delay and what medications to skip.

“I would have to trade one specialist for another and figure out what I absolutely had to be able to afford and what I can afford to let go,” said Lisa, a 55-year-old white woman living in Ohio. She has diabetes and kidney disease, with complications that make it difficult for her to hold a regular job. Lisa’s household income is about $50,000 per year for her family of two. Lisa’s premiums would increase by an estimated $179 per month if the enhanced PTCs are not extended. “It’s a hard choice because what condition do I stop treating?” she said. “What specialists would I let go? What doctor visits would I stop doing?”

“Lowering the amount of the monthly premiums makes it possible to have insurance”

Access to enhanced PTCs has provided peace of mind that may be harder to quantify but is no less impactful on a person’s quality of life. Having health insurance has provided people with the assurance that if they or their child or partner has an accident or health care emergency, their family is covered and protected from astronomical medical bills.

Darling, a 38-year-old Latina woman from Florida, cannot go without insurance because she has a chronic condition that requires regular ultrasounds. She is concerned that if the enhanced PTCs went away, she would have to enroll in a less expensive health plan that does not meet her needs. She was previously uninsured and she knows the hardship involved. “It is super expensive to pay for a medical consultation with a general practitioner. It is super expensive to pay for an ultrasound. I wouldn’t have access to these types of exams [without insurance]. [Not having insurance] would be severe for me,” she said.^a Darling works as a driver for a rideshare company and has income of about $16,000 per year. In most states, she would qualify for Medicaid, but because she lives in Florida (which as not adopted the ACA Medicaid expansion), her only affordable coverage option is the marketplace. If her income dropped much lower, she could fall into the coverage gap.

However, many enrollees would forgo coverage altogether if it was no longer affordable, even if it meant taking on the risks that come with being uninsured. Ana is a 40-year-old Latina woman living in Texas and works as a delivery driver. She would see her premiums for family coverage increase by an estimated $256 per month if the enhanced PTCs expire. “It would [not] be an option for us,” Ana said. “If it is like that, I would not pay it. Lowering the amount of the monthly premiums makes it possible to have insurance…especially because of the economy right now.”^b Ana is concerned about having to drop her insurance coverage, especially for her two young children; her household income is just over the limit for the Children’s Health Insurance Program in her state. She says that she would need to rely on safety net clinics, but the nearest one is a 40-minute drive away, has inconsistent hours, and can still be costly.

Congress must act to stop the clock from running out on enhanced premium tax credits in 2025. By taking urgent action to make the enhanced PTCs permanent, Congress can keep insurance affordable for millions of people and allow enrollees to enjoy the greater financial security, peace of mind, and stability that comes with having accessible, affordable health care.

Amy Killelea is an independent consultant and health policy researcher.