Affordable Care Act Marketplace plans are on track for a second straight year of double-digit premium increases. For context: in 2026, average premiums jumped ~20%, driven by rising medical costs, policy changes, and the expiration of enhanced subsidies.

Back in November 2025, I wrote a Huddle Trends piece asking what would happen if Congress let the enhanced ACA subsidies expire. New KFF data gives us the answer: premiums are rising, healthier people are leaving, and insurers are pricing a sicker risk pool into 2027.

In this article, I’ll review what ACA enhanced subsidies did, why they ended, and what we’ve learned so far. I’ll also walk through recent KFF data on where 2027 premiums may land (and what happened in 2026), then break down what all of this means for patients, us clinicians, and the broader healthcare system.

The American Rescue Plan Act of 2021 made two changes that fundamentally reshaped the marketplace:

These changes made ACA plans more affordable for lower-income patients, and they also pulled in middle-income, often healthier people who previously stayed out of the marketplace.

Marketplace enrollment more than doubled. In 2025, 24.3 million Americans were enrolled—a record high—and 12 million of them joined because of the enhanced subsidies.

A year after ARPA passed, the Inflation Reduction Act (2022) extended these enhanced subsidies through December 31, 2025.

Once time was up, Congress let them expire.

The obvious prediction: when premiums rise, healthier enrollees are more likely to drop coverage because they feel more able to gamble on being uninsured or underinsured. As healthier people leave the risk pool, the remaining pool gets sicker and more expensive—driving premiums up for everyone else.

That prediction is now showing up in the data: marketplace enrollment is down by roughly 3 million people, and insurers are already pricing a sicker risk pool into 2027.

In a recent analysis of premium data from insurers participating in ACA Marketplaces, KFF found a median proposed premium increase of 14% for 2027. That follows a 20% increase from 2025 to 2026. If Marketplace premiums do increase 14% (or more) in 2027, it would mark the second straight year of double-digit premium growth.

KFF highlights several drivers of these increases:

Insurers anticipate continued decline in the market in 2027.

As one example, KFF describes the following:

That’s the story in one example: the subsidy disappears, the underlying premium rises, and a middle-income enrollee gets squeezed from both directions.

This stems from a smaller, sicker, more expensive ACA risk pool, layered on top of rising healthcare costs.

Clinicians and health systems will feel the downstream effects of rising ACA Marketplace premiums—not to mention the added strain from Medicaid disenrollment and new work requirements. The ripple effect looks like this (Wendell Potter also calls this the insurance death spiral):

It hits each stakeholder differently. For many, these consequences show up as numbers on a spreadsheet. For us physicians and our patients, they show up as delayed care and avoidable deterioration.

Yes, the ACA enhanced subsidies were imperfect. They made coverage more affordable while the underlying cost structure of American healthcare continued to worsen. Letting them expire didn’t fix that cost structure—it shifted more cost onto patients and made the risk pool worse.

In practice, this “solution” mostly shifted affordability off the federal balance sheet and onto patients.

You can debate whether federal subsidies are the right long-term strategy. Removing them made coverage less affordable, pushed healthier people out, and left sicker patients facing higher premiums and deductibles. The affordability problem is now more visible and more concentrated among the patients who need coverage most.