Safford mentioned that they can’t manage the $1,800 monthly premium—which only covers her and her husband—without slashing essential expenses like food or dental care. As an alternative, they’re considering a cheaper, high-deductible plan that would cover the whole family. This comes with a trade-off: although the monthly premiums would be lower, they would face higher out-of-pocket expenses before insurance benefits start.

“Right now, we’re making a decision based on the three of us being relatively healthy,” Safford said. “But I mean, as we all know, with health, that could change any day.”

More than 24 million people got their health insurance through the Affordable Care Act in 2025, according to data from the health policy research group KFF. Of those, more than 9 in 10 — 22.3 million people — qualified for the enhanced subsidies. (That figure includes people who also qualify for the ACA’s standard subsidies for very low incomes, which went into effect in 2014 and are expected to continue.)

In Mississippi, Florida, West Virginia, Oklahoma, Louisiana, Utah and Alabama, at least 96% of ACA enrollees received enhanced subsidies. New Hampshire and Washington state had the lowest rates, at 71% and 73%, respectively.

If the enhanced subsidies expire, nearly 4 million people are projected to go without coverage in 2026 because they won’t be able to afford the premiums, according to a 2024 analysis by the Congressional Budget Office, the nonpartisan agency that advises Congress on budget and economic issues. That number is expected to balloon to almost 7 million people by 2034.

If Congress doesn’t act, “millions of people will become uninsured,” said Edwin Park, a research professor at the Georgetown University McCourt School of Public Policy. “Without these subsidies, it’ll be much more costly.”

A double whammy

Open enrollment for next year’s ACA plans begins Nov. 1.

But for many families, the “sticker shock” will come in October, when formal notices land in their mailboxes outlining next year’s monthly premiums, said Jessica Altman, executive director of Covered California, a state-based marketplace for ACA coverage.

“There’s a lot of fear,” she said. “Whether that’s someone who has cancer or a chronic condition who knows that they need it, or someone who thinks, ‘I may just have to go without and just cross my fingers.’”

In Sacramento County, Altman said as an example, a family of four earning $113,000 a year could see its monthly premium jump by about $1,550 if the government subsidies expire, compared to just $112 if subsidies remain.

On top of the subsidies expiring, states must also factor in expected premium hikes from insurers next year.

It’s “a double whammy of premiums going up and then tax credits potentially going down,” Altman said. A report from KFF found that insurers that offer ACA plans are planning an average premium increase of around 18% across the U.S. for 2026. Combined with the loss of subsidies, people could pay an average of 75% more in premiums, according to KFF.

People who still qualify for the standard ACA subsidies won’t be spared, either, said Cynthia Cox, vice president and director of the program on the ACA at KFF. Without the enhanced subsidies, the amount the government pays toward their monthly premiums will shrink.

“The effects are going to be pretty widespread,” Cox said. “Pretty much everyone who buys their own health insurance is going to be affected by this one way or another.”

In Safford’s home of Washington state, Dr. David Zonies said many of his patients will be directly affected. Zonies is the medical director at the University of Washington’s Harborview Medical Center, a safety net hospital that in large part cares for Medicaid and ACA patients.

The loss of the enhanced subsidies, along with the Medicaid cuts, means many patients will go uninsured and delay the care they need until it becomes much more serious, he said.

“The greatest concern I have right now is the loss of these tax credits,” Zonies said. “We anticipate that we’re basically going to go back to what it looked like before the Affordable Care Act was passed, and that’s going to be really devastating.”

A spokesperson for AHIP, the main industry trade group that represents insurers, including those that sell ACA plans, did not respond to a request for comment.

A fight to extend subsidies

Park said it’s still possible that Congress could extend the enhanced subsidies — either as part of a government funding package or a separate bill. The latest government spending bill expires on Sept. 30.

“It is very difficult to predict,” he said.

Democrats have continued to advocate for extending the subsidies, and many Republicans remained opposed.

But Senate Majority Leader John Thune, R-S.D., told NBC News earlier this month he is keeping the door open to a potential extension.

“It’s something that, yeah, some of our members are paying attention to,” Thune said, though he blamed Democrats for both expanding the size of the program and including phaseouts for the subsidies.

House Speaker Mike Johnson, R-La., has been noncommittal on the issue, but he similarly kept the door open to a funding extension.

Altman said Congress needs to figure out what it wants to do quickly, noting that an extension would provide not only “peace of mind” for many families, but also security in their health care and economic freedom.

A June report from KFF finds that 3 in 4 adults support extending the enhanced subsidies, including two-thirds of Republicans.

Park said that the enhanced subsidies passed by Republicans, however, may not be the same as what the Democrats previously had in place.

“I do expect that if there is any congressional Republican willingness to negotiate on an extension of the enhanced credits, they may seek to reduce the generosity of the enhanced subsidies,” he said.

Cox said some families may decide to keep their coverage by making sacrifices to their household budgets, but most, like Safford’s family, will likely transition to high-deductible plans. While people on these plans need to pay more out of pocket before coverage kicks in, the plans are designed to protect against huge medical bills that can be financially devastating.

“Let’s say that you end up getting hit by a bus, you get cancer or some really expensive medical treatment you need. That kind of plan would shelter you from those very, very high hospital costs,” Cox said.

Safford said she continues to “knock on wood” that the subsidies will be extended.

“It would take away from our life” if they aren’t extended, she said.