What am I going to do for health insurance next year?
It’s the question on a lot of people’s minds right now, especially if they have been using expanded government subsidies to make Affordable Care Act (ACA) plans… affordable?
The Affordable Care Act was passed in 2010 to expand access to insurance coverage. Premium tax credits were initially available to individuals and families with income between 100% and 400% of the federal poverty level (FPL), which in 2025 is $15,650-$62,600 for an individual and $32,150-$128,600 for a family of four.
Legislation passed in 2021 expanded access to these subsidies to people with income above 400% of the FPL, and in 2022 these subsidies were extended through the end of 2025. Which brought us to the recent federal government shutdown, due in part to battles over massive cuts to Medicaid, and whether to allow the supplemental ACA subsidies to expire.
No resolution has been reached to extend the expanded subsidies, and most experts agree that even if an agreement is reached by the end of the year, it won’t help consumers in 2026. ACA plan premiums have gone up for a number of reasons, and subsidies are currently only available to folks at 100-400% of the FPL. The best thing we can do is prepare ourselves and try to understand our options.
Here’s how I recommend you get prepared:
Pull out your 2024 tax return, analyze your pay in 2025, and estimate your income for 2026. This is the number that determines your subsidy for any ACA plan premiums. It’s okay if you estimate incorrectly, you will just pay back any overages on your 2026 tax return.
Estimate your typical annual healthcare spending, including premiums and medications. Whether or not you currently have coverage, you can review your bank or credit card statements to gather this information. If you receive care from any providers who don’t take your insurance, include the costs for these services as well.
Review your personal budget to determine how much you are truly willing and able to spend on healthcare. If you do not have a personal budget, this could be the perfect time to create one, and there are many free tools available online for doing this.
Start to compare cash prices to insurance prices. Use GoodRx or Cost Plus Drugs to find cash prices for your medications- you may be surprised at how affordable they can be! Check 90-day versus 30-day supply prices for additional savings. Consider calling your providers to ask about cash prices for appointments and services.
Find an ACA broker to work with. These folks are experts at helping you choose the best plan to suit your needs, and it doesn’t cost you a single extra cent! Be prepared with the information above, as well as the names of any doctors and hospitals you’d like to keep. A broker will input all of this information and generate the top plans with prices that come closest to your parameters. Maybe it won’t be so bad!
But if your premiums do go way up, and you’re left thinking “how can I afford health care now?” here’s one strategy to consider: you could bundle a direct primary care (DPC) membership with a catastrophic insurance coverage plan. You would pay the cost of your DPC membership, and receive enhanced access to primary care that aims to keep you as healthy as possible.
A catastrophic plan covers recommended cancer screenings at no cost, and would keep you protected for any big ticket items like emergency room visits or hospital stays. This strategy may even work for folks who need some specialist care, depending on the price of your ACA premiums versus the cash price for your specialist care.
With DPC, you will never pay a co-pay for visits, and often receive better prices for labs than you do with insurance. You’ll rarely incur the cost of an urgent care or minute clinic, because your DPC provider will see you within a day or two any time you’re sick. And your DPC provider will help you find other cost cutting measures, like the best cash prices for imaging or sleep studies, because they’re skilled at that kind of stuff!
The time and personalized attention you get from your DPC provider will pay dividends in the long run, helping you make meaningful progress with your health goals and avoiding big ticket chronic issues down the line. If you think DPC may be the right path for you, I’d love to connect, and I invite you to schedule a free discovery call today. If you haven’t fully evaluated your options yet, I’ve created an open enrollment preparation tool to get you started.
