A new analysis warns that recent Trump administration policy decisions will significantly increase health care costs for Americans who purchase insurance through the Affordable Care Act (ACA) marketplaces, particularly those living in rural areas.
Researchers at the Century Foundation found that premiums in the 32 states that rely on the federally run ACA marketplaces are projected to rise by 93% once Biden-era tax credits expire at the end of this year. The administration’s refusal to support an extension of these subsidies, combined with other regulatory and tariff changes, is expected to lead to significant increases in out-of-pocket costs.
Rural residents will bear the heaviest burden, with premiums projected to rise by 107%, compared to an 89% increase for those in urban areas. Insurers participating in the ACA exchanges have also proposed an 18% median premium increase in 2026, the largest increase since 2018 and significantly higher than this year’s adjustments.
According to the foundation’s report, approximately 2.8 million marketplace enrollees currently live in rural areas, including more than 776,000 adults aged 55 to 64 and more than 223,000 children.
“Rural residents are typically older and more likely to have chronic conditions,” explained Jeanne Lambrew, director of health care reform at the Century Foundation. “Not only do they have greater health care needs, but they also have fewer options for accessing care, which makes insurance more expensive.”
Rural enrollees are projected to pay an average of $760 more per year, 28% more than their urban counterparts. The largest increases are projected in Wyoming ($1,943), Alaska ($1,835), and Illinois ($1,700).
The problem is exacerbated in states with large rural populations that chose not to expand Medicaid under the Affordable Care Act (ACA).
Millions of residents with incomes between 100% and 138% of the federal poverty level (approximately $15,650 to $21,597 per year for individuals) must rely entirely on the ACA marketplace for coverage.
Of the seven states where at least 10% of marketplace enrollees live in rural areas, only Nebraska and North Carolina have expanded Medicaid coverage.
State officials are urging residents to carefully evaluate their options. Pennsylvania Insurance Commissioner Michael Humphries recently advised consumers to “shop around more than in years to find the plan that best meets their healthcare needs and current financial situation.”
Without affordable options, many people may simply forgo insurance altogether, Lambrew warned. “This will harm their health and lifespan, increase the strain on healthcare providers who must treat sicker patients, and drive up costs for society as a whole.
We know that health insurance saves lives—so it’s deeply troubling to see millions of Americans without access to it.”