As Missourians confronted higher health insurance costs for their Affordable Care Act coverage in 2026, tens of thousands chose higher-deductible plans, while many chose to go without insurance altogether.
Takeaways
- Rising Affordable Care Act costs are pushing Missourians toward cheaper plans with higher deductibles and co-pays.
- Many are staying insured, but opting for higher financial risk with their plan selections.
- The shift could lead to more people struggling to afford care, or dropping their ACA health insurance coverage entirely.
The trend was expected as enhanced premium tax credits lapsed for this year. The credits were subsidies provided to ACA enrollees to help cover the costs of their plan, but the subsidies were central
Although some advance tax credits were still available to marketplace customers, costs jumped for most looking to shop for a plan.
Overall, 1.2 million people nationwide opted out of the ACA marketplace in 2026. In Missouri, nearly 51,000 people dropped their ACA coverage for the year, while thousands more chose plans with higher out-of-pocket costs. It remains unclear how many may drop their plans entirely after receiving their first few bills of the year.
In Missouri, silver plan enrollments dropped by nearly 18 percentage points, while bronze and gold plans increased by 15.3 percentage points and 2.2 points respectively, according to an analysis of Centers for Medicare and Medicaid Services data by Timothy McBride, a health economist and professor at Washington University.
But by going for lower premiums, Missourians could be trading lower monthly payments for higher costs at the doctor’s office if they get sick.
“People are making very difficult choices of recognizing that they need to pay a certain amount for premiums, but also recognize that when they get sick, if they choose a bronze plan, it’s going to cover a lot fewer services, and they’re going to have to pay a lot more,” said Gerard Anderson, a professor at the Johns Hopkins Bloomberg School of Public Health.
How Missourians made their Affordable Care Act decisions
The trend was prominent for Gina Martin, a benefits counselor at Aging Matters in Cape Girardeau. She’s been enrolling Missourians since the ACA came online, and helps those aged 60 to 64 find and select their plans.
Many of her clients shifted from silver to bronze plans for 2026.
“Because I’m with a window of folks where it’s only a couple of years that they might have to be on the marketplace … they were willing to go for the higher deductible and more bronze plans were chosen,” Martin said.
Despite downgrading their plans, Missourians also faced higher premiums. On average, premiums rose about $103 a month for those enrolled in marketplace plans from 2025 to 2026.
Martin said the rise in premiums wasn’t as high as most people were expecting. But many still opted for higher deductibles and co-pays as opposed to the higher monthly rates, citing their savings to help them cover those new costs.
“They weren’t looking at it as catastrophic,” Martin said. “If you do get sick, and there’s some savings, they’re like, ‘Well, at least we won’t be bankrupt.’ For $8,000 for their maximum out-of-pocket, it’s a lot, but at least that’s better than a full $400,000 hospital bill.”
Still, for some people Martin helped get enrolled, the sticker shock was unavoidable. She pointed to a widow who had been collecting a widower’s pension that put her income above the levels to collect the subsidies.
Her monthly cost jumped from about $350 for premiums in 2025 to more than $1,600 a month for 2026.
“She has to have insurance for all of her medical conditions, and she isn’t 65 yet,” Martin said.
“In her case, she had (the money to pay), but if that would have happened to a couple and maybe they were self-employed, and their cost went from $350 to $1,600?” Martin said. “You can’t do it.”
Rural areas face higher premiums than urban, data finds
Missouri outpaced the nation when it came to premiums rising for ACA plans in 2026, McBride’s analysis found. Nationwide, out-of-pocket premiums rose nearly 58%, compared to a 90% jump in out-of-pocket premiums in Missouri.
For Missourians living in rural areas, premiums tend to be higher because of a lack of market competition, McBride said.
“I can tell you from looking at this over time that all of this is market-driven. People in St. Louis tend to have more choices than those outstate,” McBride said. “Paradoxically, even though the cost of living is higher in St. Louis and Kansas City and the metro areas, the premiums are higher in rural areas.”
With fewer people living in rural areas, there are fewer people to enroll in marketplace plans, making it difficult for insurers to compete. More often than not, insurers in rural areas have little competition, driving costs higher.
With two or more plans in a region, premiums can drop.
In the Aging Matters coverage area, for example, which includes 18 counties in southeast Missouri, three insurers are on the ACA marketplace, which can keep premiums lower.
The problem for many people Martin helps enroll, though, is the major hospital system in the area accepts few of those plans, making it difficult for marketplace customers to stay with their doctors.
“The shift for people becomes what hospitals in our region will take (marketplace plans),” Martin said.
Martin said that’s usually the first thing she addresses with people looking for marketplace plans.
It’s a trend happening nationwide, Anderson said.
“It’s particularly difficult to be in a rural community these days, because you have fewer choices in ACA plans, then you have fewer choices as Medicare beneficiaries and across the board,” Anderson said.
And new data shows that health care spending is back on the rise. Even for those on employer-sponsored health insurance plans, costs are rising.
“An average insurance policy for someone who has employer-based insurance is about $27,000 a year, and people who have to pay that themselves probably don’t have anything close to $27,000 a year to spend,” Anderson said. “If that is the standard level of care, we’re going to have to subsidize people to that level for them to afford insurance.”
Looking ahead, both Anderson and McBride worry what the uptick in health care spending means for low-income people across the country.
“I think people are going to say, ‘I’m buying insurance, it’s not covering what I need it to cover. And when it does cover what I need, it pays a small portion of the bill. Do I really need insurance?’” Anderson said.
“People are dropping out of the system,” he said. “It’s unclear how fast they’re dropping, but the clear trends are people dropping out of the system, leaving the sickest people enrolled, and those people are going to have difficulty affording care in the future.”
