When Madison Thimmesch turned 26 and had to give up her parents’ health insurance coverage, she was finishing college at the University of Missouri-Kansas City. 

She didn’t have a full-time job and easy access to another insurance plan. So, like millions of other Americans, Thimmesch turned to the Affordable Care Act marketplace. There, she found the coverage she needed — including dental — for only about $12 a month.

“I had been really stressed about not having health insurance,” she said.

It worked out for Thimmesch thanks largely to the tax credits she could get, which offset the true cost of her insurance. Congress adopted enhanced tax credits in 2021 to help low- and middle-income Americans afford marketplace coverage.

But those tax credits are set to expire at the end of the year and Congress does not appear poised to renew them. If they go away, an insurance plan like the one Thimmesch relied on to get through college will become unaffordable for many people. 

The nonprofit Commonwealth Fund estimates that Missourians receiving tax credits for marketplace coverage would pay about $720 more on annual premiums if the enhanced credits expire. Kansans would see premiums go up about $590 a year.

“It’s going to be a major sticker shock for a lot of people,” said Sara R. Collins, who studies health care access at the Commonwealth Fund.

The most likely outcome of skyrocketing premiums, many experts believe, will be millions of people dropping insurance altogether. The Commonwealth Fund report estimates that 51,000 Missourians will become uninsured if the tax credits expire, while 66,000 Kansans will become uninsured.

‘Catastrophic change’ to insurance

All told, 4 million Americans are expected to become uninsured if the tax credits expire. And other bureaucratic changes to the Affordable Care Act proposed in President Donald Trump’s One Big Beautiful Bill Act could lead to an additional 4 million people losing marketplace coverage.

Meanwhile, the Trump administration’s proposed federal cuts to Medicaid, insurance that covers low-income and disabled Americans, are expected to cause an additional 8 million Americans to be left uninsured.

“Sixteen million people would be uninsured in a relatively short period of time,” Collins said. “It’s a catastrophic change to our insurance system.”

And it threatens to upend health care coverage gains that have been seen across the country in recent years. According to a state-by-state Health Scorecard that the Commonwealth Fund published June 18, uninsured rates fell in every state between 2013 and 2023.

According to the scorecard, the share of working-age adults without health insurance fell to 11% nationwide in 2023 from 20.4% a decade earlier. And only 11.7% of adults reported skipping care because of cost in 2023, compared with 15.9% in 2013.

In Missouri, 11% of 19-to-64 year olds were uninsured in 2023, compared with 14% in 2019. And 12% of Kansans in that age group were uninsured in 2023, compared with 13% in 2019.

Authors of the scorecard attributed the improvements in insurance coverage to added premium tax subsidies that boosted enrollment in the Affordable Care Act marketplace, and to Medicaid expansion, which helped more people qualify for Medicaid coverage.

The loss of insurance won’t be felt only by the patients left without coverage. Hospitals, doctors’ offices and community health centers that rely on revenue from insured patients to keep the doors open will all feel the decline in the number of people who have insurance.

“Those losses also trickle through the economy,” Collins said.

The American Hospital Association in a statement urged Congress to extend tax credits. Losing them, the group said, would lead to greater numbers of uninsured patients, placing “considerable financial stress” on hospitals and a potential loss of services. The organization cited research indicating that, over the course of a decade, the loss of the tax credits could result in a $28 billion reduction in hospital spending.

The ACA marketplace has become an increasingly important part of the health insurance system. The number of people enrolled in health insurance plans through ACA marketplaces has more than doubled in recent years, reaching 24.3 million in 2025, up from about 11.4 million five years earlier.

In Missouri, 417,000 individuals enrolled in the marketplace this year, up from 202,000 in 2020. And in Kansas, more than 200,000 individuals enrolled this year, compared with less than 86,000 in 2020.

Tim Becks, an insurance broker who owns Becks Benefits Design in Westwood, said he would be shocked if the tax credits go away entirely. But if Congress does let them expire at the end of the year, it will be devastating to the marketplace, he said.

“If you get rid of tax credits,” Becks said, “you’ll just see it bleed down.”

Healthy young people will drop out of coverage, leaving older and sicker patients behind. Coverage costs will go up, and insurance companies won’t want to participate.

Households paying more

Complicated formulas taking into account age, income and family size, among other factors, determine how much people pay for insurance through the marketplace in each state. 

Without tax credits, which basically provide a discount on the cost of coverage, higher-income people will see especially steep rate increases for marketplace plans. And people making more than four times the federal poverty level won’t get any help paying premiums at all. 

A state-by-state analysis by Charles Gaba of ACASignups.net ran the numbers for various household scenarios to determine how much the loss of tax credits would increase premiums.

Gaba predicts that, if subsidies expire, beginning next year in Missouri:

• A single 50-year-old making $40,000 a year will see premiums go from $154 per month to $258 per month.
• A single parent making $40,000 will see premiums jump from $61 per month to $185.
• A family of four with income of $60,000 will see monthly premiums increase from $84 to $270. 
• And a 64-year-old couple making $90,000 will have to pay more than $26,000 a year for coverage.

And in Kansas: 

• A single 50-year-old making $30,000 a year will see premiums go from $49 per month to $142 per month.
• A single parent making $40,000 will see premiums jump from $60 per month to $270.
• A family of four with income of $60,000 will see monthly premiums increase from $84 to $270. 
• And a 64-year-old couple making $90,000 will have to pay more than $21,000 a year for coverage.

Becks said he is telling his clients not to panic, and hoping lawmakers will realize how many people will be affected if they don’t act. 

In the meantime, he is keeping his eye on a more immediate problem: The imminent departure from the ACA marketplace of Aetna, an insurance company owned by CVS. Becks said 80% of his marketplace clients are enrolled through Aetna this year because “they have the best network on the ACA.”  

“We’re going to have to figure out alternative options,” Becks said. 

Additional obstacles

The budget reconciliation bill that the House passed, which is now making its way through the Senate, would add further obstacles for patients to navigate, even if the tax credits stay in place. The version of the bill that passed the House:

• Shortens the marketplace’s enrollment period by a month, meaning people would only have six weeks to sign up — Nov. 1 through Dec. 15. And if they miss that enrollment window, the bill makes it harder to enroll at other times.
• Establishes stricter eligibility verification processes, like requiring applicants to provide documents to show proof of income, family size and insurance status. Previously that information was verified seamlessly through government databases.
• Ends automatic reenrollment, which is how almost half of marketplace participants keep coverage.
• Lets insurers deny coverage to people who owe money on previous premium bills.
• And makes many lawfully present immigrants ineligible for subsidized marketplace coverage. That includes “Dreamers” — people in the Deferred Action for Childhood Arrivals program — and legal immigrants who are in a five-year waiting period to receive Medicaid.

Yvette Carias Solis, a health navigator with El Centro, which provides services to Hispanic and Latino residents in Wyandotte and Johnson counties, said losing affordable marketplace coverage will leave many of her clients who have ongoing health problems without care and medicine.

“It’s just a snowball effect,” Carias Solis said. “It’s not just for the individual, but also for the community.” 

Families already are dealing with high costs of housing and rent, she said. Adding higher insurance costs on top of that will force them to make difficult decisions.

“Do I pay for food this week, or do I get my medication?” she said.

Molly Gotobed, executive director of the Community Health Council of Wyandotte County, said that for many of the people she knows who have coverage through the marketplace it won’t be a choice at all. 

“I’m guessing most people (facing higher premiums) just aren’t going to have health insurance,” she said. Or they will purchase policies with high out-of-pocket costs.

The result will be a step back to a time when people were sicker because they couldn’t afford health care, Gotobed said.

“I just think the whole thing is terrible. So many people are going to lose coverage.”