ACA Subsidies in 2026: What's Known, What's Uncertain, and Why It Matters

Twenty-two million Americans entered 2026 paying more for health insurance, and in many cases, more than double what they paid in December. Enhanced Affordable Care Act (ACA) subsidies expired on December 31, and Congress hasn't produced a solution yet. The House passed an extension last week with 17 Republicans breaking ranks, but Senate leadership says there's "no appetite" to move. A compromise could come next week - or it might not come at all.

For providers, the uncertainty is already creating operational problems: patients dropping coverage, shifting payers, showing up with plans they don't fully understand. Revenue cycle teams can't afford to wait for Washington to figure this out.

In this piece, we're breaking down what's known, what's uncertain, and what to do right now.

How the Change Affects Patient Populations

The expiration affects 22 million marketplace enrollees - 92% of the ACA marketplace population - and the size of impact is large. KFF projects premiums will more than double on average, rising from $888 to $1,904 annually (a 114% increase). CBO estimates up to 4 million people could lose coverage entirely without an extension.

The affordability pressure is already reflected in enrollment patterns. 59% of enrollees selected bronze plans for 2026, up from 49% in 2025, with patients trading lower premiums for higher deductibles to stay insured. The "subsidy cliff" is also back - patients earning over 400% of the federal poverty level lose eligibility entirely instead of having assistance reduced.

Patients are dropping marketplace plans, shifting to Medicaid or employer coverage, or going uninsured. New sign-ups are down considerably in Pennsylvania and California, and state-based exchanges saw an 18% decrease in new customers overall. 

Operational Impact for Revenue Cycle Teams

The shift toward bronze plans makes collections harder downstream. More patients are showing up with high-deductible coverage (a $5,000+ out-of-pocket exposure is now common) which means more collection risk and difficult cost conversations at the front desk.

All of this churn contributes to substantial eligibility verification problems. Patients who had marketplace coverage in December may now be on Medicaid, employer plans, or nothing at all just a month later. Some switched to bronze plans with completely different cost-sharing structures. Others crossed the “subsidy cliff” and lost eligibility entirely. And if Congress does act, coverage could shift again mid-quarter. Eligibility verified last month may already be wrong - and without proactive reverification, denied claims will pile up.

What Providers Should Do Now

Build systems now to track coverage changes in real time and re-verify eligibility for marketplace patients before they arrive. Front desk and billing teams should expect more cost conversations - and have the tools to handle them.

Some states have partial offsets worth watching. California allocated $190 million to cover enhanced subsidies for its lowest-income enrollees. Massachusetts has longstanding state-level subsidies that provide additional cushion. These offsets won't solve the problem, but they may soften the impact for some patients.

Nirvana tracks these kinds of policy developments to equip providers with the most complete picture available - because building trust in healthcare requires transparency at every level, from individual patient costs to the policy changes that affect them.