How lowering premiums for all marketplace plan types keeps costs down

There’s a significant shift in the health insurance landscape happening right now that will influence access to care for millions of Americans for years to come. The Affordable Care Act’s (ACA) enhanced premium tax credits (EPTC) expired at the end of 2025, doubling premiums on average for Marketplace enrollees in 2026 plans. Most states saw ACA Marketplace enrollment drop as EPTCs expired. In North Carolina, enrollment fell by 21% — the largest decline for a single state in the entire country. South Carolina saw its enrollment fall 6.6%. Open enrollment is closed for 2026, but the debate that will shape 2027 Marketplace plans and their cost to enrollees is ongoing.

Replacement proposals

EPTCs were established in 2021 during COVID in addition to established premium subsidies for ACA Marketplace plans. They expanded who was eligible for these plans and significantly reduced premiums.

These tax credits were temporary and Congressional efforts to extend them when they expired in 2025 were unsuccessful. For some patients, their expiration caused insurance premiums to jump as much as $22,000 per year. The steep increase has already pushed millions of people to forgo Marketplace coverage and go without insurance entirely.

To mitigate some of that impact, the Trump administration and Congressional Republicans are considering proposals that change how premium subsidies are delivered. Instead of tax credits that can be sent directly to insurance companies, in one proposal, enhanced subsidies would instead be sent directly to patients as Health Savings Accounts (HSAs).

Patients can use HSA dollars to pay for healthcare expenses like doctor visits or prescription drugs, but they can only be paired with eligible High Deductible Health Plans (HDHPs), which have lower monthly premiums and higher out-of-pocket costs.

The 2025 H.R. 1, also known as the One Big Beautiful Bill Act, increased the number of HDHPs that are eligible to be combined with HSAs in the Marketplace. However, even with the proposed HSA subsidy, HDHPs do not offer the level of coverage that many enrollees with chronic conditions need to manage their conditions.

The effects of more HDHPs

Adults with chronic and mental health conditions account for 90% of the $4.9 trillion spent every year on health care in the United States. Preventive care is critical to keeping those expenditures as low as possible.

Studies show that while HDHPs might save enrollees money on the front end with lower premiums, patients may delay necessary medical care because they are often required to pay 100% of costs until their deductible is met.

For instance, a 2025 study showed how access is limited for people with chronic conditions under HDHPs. Enrollees were less likely to schedule recommended clinic visits (-3.1%), use recommended prescription drugs (-9%) and get recommended annual lab testing (-5.7%) than non-HDHP enrollees.

The same study points out that about half of U.S. households of individuals younger than 65 do not have enough liquid assets to pay the mean HDHP deductible.

These two findings —delayed care and resulting bills HDHP enrollees can’t afford — impact costs for everyone.

Delaying chronic condition care results in increased emergency department visits and sometimes mortality. Emergency visits are more expensive for patients than preventive care and put more strain on hospital resources. When patients can’t pay their bills, premiums for others increase to make up the difference.

The solution

While HDHPs are a health insurance option some patients should consider, these plans aren’t for everyone. That’s why in the Marketplace, catastrophic-level HDHP options are typically only available to people under 30 who are at the peak of their physical health.

The Novant Health Center for Public Policy Solutions believes any policy or legislative plan that seeks to replace EPTCs should prioritize protecting patient access to care. That will require policies that keep premium costs affordable for plans that offer comprehensive medical and cost-sharing coverage, such as the current Platinum, Gold and Silver plans offered on the Marketplace. Doing this would ensure that people with chronic conditions maintain access to the preventive care they need.