As the future of enhanced Affordable Care Act health insurance premium subsidies remains uncertain, Texans who rely on ACA marketplace coverage say rising costs could force them to make hard choices between health insurance and basic necessities.
That is the central finding of a new report from Episcopal Health Foundation, which partnered with Treaty Oaks Strategies and a Harris County-based Marketplace health insurer to conduct focus groups with Texans enrolled in ACA plans. The report captures how enrollees are already experiencing higher premiums and what they expect will happen if the enhanced subsidies expire.
Participants consistently pointed to affordability as the deciding factor in whether they can stay insured. Many said their coverage only works because subsidies keep monthly premiums within reach. Without that financial help, nearly all reported they would struggle to maintain coverage. Several described scenarios where paying for health insurance would compete directly with rent, food, or utility bills.
“When affordability ends, people delay care, lose access to doctors they trust, and turn to an already stretched safety net,” said Dr. Ann Barnes, EHF’s president and CEO. “What we heard in these focus groups should be a warning about what is at stake.”
Beyond cost, focus group participants emphasized the importance of continuity of care. Enrollees said maintaining access to trusted doctors, specialists, and medications shapes how they choose health insurance plans and whether they remain enrolled. Participants expressed concern that higher premiums, narrower medical provider networks, or changes in pharmacies or formularies could disrupt ongoing care, particularly for people managing chronic conditions.
The report also highlights that the impact of expired subsidies would not be evenly distributed. Texans with lower incomes and those with chronic health needs said they would be most affected. Some participants anticipated delaying care or skipping treatments altogether. Others said they would likely shift to lower-cost plans with fewer benefits and higher out-of-pocket costs, even if that meant less comprehensive coverage.
If Marketplace coverage becomes unaffordable, many participants said they would turn to safety net providers. Federally Qualified Health Centers were frequently cited as an option, though familiarity and expectations varied. Some participants raised concerns about wait times and continuity of care, while others assumed access would be straightforward. The report warns that an influx of newly uninsured patients could place additional strain on safety-net providers across Texas.
Taken together, the findings suggest that enhanced subsidies play a critical role in keeping Texans insured and connected to care. Participants’ experiences point to broader consequences if affordability declines, not only for individuals and families but also for clinics, hospitals, and the health care system statewide.
The full report, When Affordability Ends: Texas Marketplace Members Respond to ACA Subsidy Changes, provides detailed findings and direct quotes from Marketplace enrollees describing their concerns and decisions.