Federal help still covers much of the monthly bill for most marketplace shoppers. The harder question this enrollment season is whether families can afford to use the coverage they buy.
By EEW Magazine Online Health & Wellness Editors
An Obamacare sign hangs outside an insurance agency in Miami on Nov. 12, 2025. Open enrollment for 2027 marketplace coverage begins Nov. 1. (Joe Raedle/Getty Images)
Nikisha Wheeler, a 48-year-old single mother in West Virginia, is managing lupus and related chronic conditions that require steady medical care. In 2026, she sold her modest cottage to help cover her medical expenses. The money from the sale is already gone, and the premium on her Affordable Care Act marketplace plan keeps climbing. Going without coverage would leave her paying for that care on her own.
"I may have to drop my health insurance," Wheeler told EEW Magazine Online. "But out-of-pocket costs are too much."
Wheeler is among the roughly 19.2 million people who had marketplace coverage as of February, and as open enrollment for 2027 begins Sunday, many of them face a version of her dilemma. They can pay more each month to keep adequate coverage, choose a cheaper plan that may leave them struggling to afford care, or risk going without insurance altogether.
The average premium for a benchmark silver plan, the plan the federal government uses to calculate financial assistance, is rising 13% for 2027, according to an analysis released Friday by KFF, a health policy research organization. That follows a 26% increase for 2026, bringing the rise to about 42% over two years. Those figures reflect what insurers charge before subsidies, and what a household actually pays depends on whether it qualifies for help.
Most enrollees qualify for federal tax credits, which grow as benchmark prices rise and absorb much of the increase. People who earn too much to qualify pay the full price. For 2027, the limit is $63,840 for a single person and $132,000 for a family of four. Wheeler earns $68,000 a year as a director at a nonprofit and has no dependents. She does not qualify for federal help, so she pays the full premium.
For those who do qualify, the relief has limits. Louise Norris, a health policy analyst with HealthInsurance.org, told West Virginia Watch that costs for subsidized shoppers should hold roughly steady from this year, at a level well above what they paid in 2025. "So some folks who were able to make it work in early 2026, might not be able to continue that all the way into 2027," she said.
Many subsidized shoppers will still find low monthly prices. More than 75% of HealthCare.gov shoppers will have access to a plan costing $50 or less a month after tax credits, the Centers for Medicare & Medicaid Services said in its 2027 fact sheet. Those low-premium plans often carry the largest deductibles, the amount a patient pays for many services before insurance begins to share the cost.
That trade-off played out across the market in 2026, the first year without the enhanced federal tax credits Congress created in 2021 and allowed to expire last December. The share of enrollees choosing bronze plans, which pair low premiums with high deductibles, rose from 30% to 40%. The average marketplace deductible climbed by $1,027 to a record $3,786, according to a KFF analysis.
Lester Johnson, a restaurant owner in Richmond, Virginia, stands beside a sign about rising Affordable Care Act premiums during a news conference on Capitol Hill on Sept. 16, 2025, where Democratic senators and advocates called on Republicans to extend the enhanced tax credits. (Andrew Harnik/Getty Images)
For lower-income shoppers, that switch can cost more than it saves. Cost-sharing reductions, which lower deductibles, copayments and out-of-pocket limits for eligible enrollees, are available only with silver plans. A shopper who moves to bronze to cut the monthly premium gives up that protection. In 2026, the share of enrollees in silver plans with those reductions fell to 37%, the lowest on record.
For someone managing lupus, diabetes, high blood pressure or another chronic condition, the distance between a plan's monthly price and its full cost can be wide. Marketplace plans cover recommended preventive care at no cost, and some cover certain services before the deductible is met. Many still require patients to pay for specialist visits, lab work or prescriptions until they reach a deductible that can run into the thousands of dollars.
A fingertip blood sugar test uses a glucose meter and test strips, supplies that people managing diabetes may need month after month. (Getty Images)
The maximum out-of-pocket limit federal rules allow is also rising, from $10,600 per person in 2026 to $12,000 in 2027, Norris said, though individual plans may set lower limits.
West Virginia shows how quickly that pressure builds. The state has the nation's highest average marketplace premiums, according to HealthInsurance.org. "West Virginians simply can't afford 200%, 300% and even higher premium increases," Ellen Allen, executive director of West Virginians for Affordable Health Care, told West Virginia Watch in January, after the enhanced credits expired. Choices there are changing for 2027 as well.
CareSource is leaving the state's marketplace, and Peak Health, owned by WVU Medicine, Marshall Health and Valley Health, is joining Highmark Blue Cross Blue Shield. CareSource customers who renew automatically will be moved to one of the remaining insurers and should confirm that their doctors and prescriptions are covered.
The Highmark sign tops Fifth Avenue Place, the company’s headquarters in downtown Pittsburgh. Highmark Blue Cross Blue Shield West Virginia will sell marketplace plans in the state in 2027 alongside newcomer Peak Health. (Jim Harris/Pittsburgh Business Times)
Insurers attribute the rising prices to higher costs for hospital care, prescription drugs and medical labor. They also say healthier customers were more likely to drop coverage after the enhanced credits expired, leaving a pool with greater medical needs. In filings reviewed by KFF, insurers estimated that shift added about 4 percentage points to 2026 premiums, and they expect a similar effect in 2027.
Nationally, marketplace enrollment in February 2026 was down 2.6 million, or 12%, from a year earlier, according to KFF. Some of those people moved to employer coverage or Medicaid. In a KFF survey, about 9% of 2025 marketplace enrollees said they became uninsured for 2026.
The consequences weigh heavily in Black communities, where coverage gaps have narrowed since the ACA took effect and still persist. In 2024, 10.1% of Black Americans under 65 were uninsured, compared with 6.8% of white Americans, according to a May 2026 KFF report. Disproportionately large shares of Black Americans are covered through Medicaid and the ACA marketplaces, and KFF researchers project that coverage losses in those programs will likely widen racial disparities. Many Black women hold coverage through an employer, Medicare or other sources; the figures point to a structural pattern across the community.
Where a person lives also shapes her options. In the 10 states that have not expanded Medicaid, an estimated 1.2 million adults fall into a coverage gap, earning too much for their state's Medicaid program and too little for marketplace subsidies, which begin at the poverty line, according to KFF. Hispanic and Black adults make up 56% of that group. For a parent in that gap with a chronic illness, a lapse in care can mean missed medication, skipped screenings and complications that cost more to treat later.
Shoppers can protect themselves by comparing the full yearly cost of a plan, including the deductible and out-of-pocket maximum, alongside the premium. HealthCare.gov's plan comparison tool estimates total yearly costs based on income and expected use. Lower-income shoppers who expect regular care should price silver plans with cost-sharing reductions before choosing bronze.
Jeremy Smith, program director for First Choice Services, which runs West Virginia's navigator program, said automatic renewal isn't the best option. "So go back into their healthcare.gov account, update their application with their new income, and then actively look at the new plans and prices," he told West Virginia Watch. "We strongly encourage anyone and everyone that's on the marketplace to do that." Smith also warned against scam sites and unsolicited sales calls. "There's been a lot of people that get phone calls and they end up enrolling in stuff that's not even real insurance, and then they don't know it till it's too late," he said.
Free help from trained navigators and certified counselors is available nationwide through HealthCare.gov's local help directory. Accurate income estimates matter more this year. Limits on repaying excess advance tax credits were eliminated beginning with the 2026 tax year, so enrollees who underestimate their income could owe the full difference at tax time.
People whose income has dropped should check whether they or their children qualify for Medicaid or the Children's Health Insurance Program, which accept applications year-round through Medicaid.gov.
Enrollees who believe the marketplace miscalculated their eligibility can file an appeal. In West Virginia, First Choice navigators can be reached at 304-356-5834.
On HealthCare.gov, which serves West Virginia and most other states, open enrollment runs Nov. 1 through Jan. 15. Shoppers who choose a plan by Dec. 15 will have coverage starting Jan. 1, and those who enroll after that will have coverage starting Feb. 1. States that run their own marketplaces set their own deadlines.
Wheeler said she has explored the options available to her and still faces an impossible financial decision. Without federal help, she pays the full price of any plan she chooses, and the plans with lower premiums would likely leave her covering more of the cost of managing lupus herself.
For families weighing a lower monthly bill against a deductible they may never meet, the plan they choose in the coming weeks will shape how they get care, and what it costs them, throughout 2027.