For the past several years, enhanced ACA tax credits made Marketplace coverage genuinely affordable for millions of Americans. Enrollment doubled, growing by more than 12 million new enrollees after enhanced credits were implemented. For covered entities, this was also a major opportunity: more insured patients meant more revenue from commercial reimbursements, and more patients reached through PIAP-supported enrollment.
Now those credits are under threat, and the impact is already being felt. ACA premiums for 2026 have jumped significantly, and according to a new analysis from Healthinsurance.org, consumers are responding by fleeing to Bronze plans — the lowest-premium, highest-deductible option — or dropping coverage entirely.
The Numbers Are Striking
KFF’s 2026 Health Care Cost tracking shows premiums rising across every plan tier. Reporting from TheStreet reveals that millions of Americans are already skipping meals to afford their healthcare costs. Without the enhanced credits, an estimated 20 million people face higher premiums — many of whom enrolled for the first time only because those credits made coverage affordable.
The movement toward Bronze plans is particularly concerning for the patients covered entities serve. Bronze plans come with high deductibles — often $5,000 or more — which means patients may technically have insurance but still skip medications or delay care because they can’t afford the cost-sharing. For patients managing chronic conditions like HIV, diabetes, or cancer, this isn’t just a financial inconvenience. It’s a health crisis.
A patient with a Bronze plan and a $6,000 deductible who can’t afford to use it is, for most practical purposes, uninsured.
What This Means for Safety-Net Providers
If your organization serves a patient population that has benefited from enhanced ACA subsidies, you may be looking at a wave of coverage disruptions. Patients who enrolled in Silver or Gold plans with $0 or near-$0 premiums may find those same plans suddenly cost hundreds of dollars per month. Without assistance, many will drop coverage — or downgrade to plans that offer inadequate protection.
This is a problem your organization can help solve, and a PIAP is the most powerful tool available for doing it.
How PIAP Addresses the Subsidy Gap
A Premium Insurance Assistance Program (PIAP) helps eligible patients enroll in ACA Marketplace plans and covers their monthly premiums — often fully — using your organization’s 340B savings or other available funding. Unlike government assistance programs that depend on annual appropriations, PIAP funding is controlled by your organization and can be targeted precisely to the patients who need it most.
When a patient is enrolled through PIAP, they’re not on a Bronze plan with a $6,000 deductible they can’t use. They’re enrolled in a comprehensive plan selected through careful formulary analysis, with premiums covered and year-round enrollment support. American Exchange also provides dedicated advocacy throughout the year — ensuring patients stay enrolled, medications stay covered, and your organization continues to see commercial reimbursements from those patients.
With ACA subsidy uncertainty expected to persist through 2027 and beyond, now is the time to build PIAP capacity in your organization — before the coverage gap widens further.
American Exchange helps covered entities and Ryan White providers design PIAP programs that keep patients insured even when federal subsidies fall short. Don’t wait for the cliff — contact us to learn how PIAP can protect your patients and strengthen your organization.
Sources
5 Points on the Impact of Congress Letting ACA Subsidies Expire — Talking Points Memo
Higher ACA Premiums Push More Marketplace Consumers Toward Bronze Health Plans — Healthinsurance.org
Millions of Americans Are Skipping Meals to Pay for Health Care — TheStreet
Eight Trends Shaping 2026 Health Care Costs — KFF
NABIP Comments to CMS on Proposed 2027 ACA Marketplace Rule — InsuranceNewsNet
