CEO BLOG:

What happens if the ACA subsidies expire at the end of the year?

Here are key facts about the subsidy change:

• Enhanced premium tax credits (PTCs) that reduced marketplace premiums for many enrollees are set to expire at the end of 2025.
• If they expire, the assistance for many marketplace enrollees will shrink or vanish — meaning subscriber premium contributions will go up.
• For example, estimates are that net premiums could increase by 75% or more on average for subsidized enrollees if the enhancements aren’t extended.
• Also: many enrollees whose incomes are above 400% of the federal poverty level (FPL) could lose eligibility for subsidies entirely, reversing the temporary expansion of subsidy eligibility above 400% FPL.
• Because of this, enrollment in ACA marketplace plans is projected to drop if subsidies expire.
• Premium rates (gross) may also rise because the risk pool could worsen (healthier individuals drop out) which insurers already are referencing in their rate filings.

What this means for your NP-owned practice

As a practice owner (especially if you serve self-employed individuals, freelancers, uninsured or under-insured populations, or rely somewhat on patients with marketplace coverage), here are some of the issues you might face:

Potential challenges

• Patient affordability and access: If marketplace premiums go up, some patients may drop or reduce their insurance coverage. That may lead to more uninsured or under-insured visits, increased uncompensated care, or no-shows because of cost concerns.
• Volume changes: If fewer people maintain marketplace coverage, your patient base might shift (fewer insured patients means higher risk for you of patients delaying care or avoiding visits).
• Mix of payer risk: A shift toward more uninsured patients or patients with less coverage may reduce your average payment per patient (if you provide care out-of‐pocket or sliding scale) or raise your administrative burden (billing difficulties, bad debt).
• Negotiation/contract pressure: Some insurers may increase premiums or reduce plan offerings. That may indirectly influence provider reimbursement dynamics or network access.
• Planning uncertainty: Without knowing whether subsidies will be extended, insurers and providers are in a uncertain environment which makes budgeting and forecasting harder for your practice.

Potential opportunities

• New patient growth: If premiums increase and people drop employer-coverage or marketplace coverage, they might seek lower-cost care alternatives (like NP-led practices) especially if you offer more affordable, flexible models.
• Value-based/cost-effective care positioning: Your practice can position itself as a lower‐cost alternative for routine / primary care, which becomes more attractive when insurance costs rise.
• Population health / outreach: You may find an opportunity to reach self-employed or independent workers whose marketplace coverage becomes more burdensome — you could offer self-pay packages or membership models.
• Strategic partnerships: With insurer changes ahead, you could explore alternative models (direct primary care, hybrid models) that appeal when coverage becomes less generous or more expensive for patients.

Operational & financial considerations

• Review payer mix: What portion of your patient base has marketplace‐insurance vs other coverage vs uninsured?
• Monitor trend in patient cancellations or changes in coverage termination: Supplemental ask your front-desk or billing team to flag when patients report higher premiums or dropping plans.
• Evaluate sliding scale/out-of-pocket pricing: If more patients shift to self‐pay, do you have a model for that pricing or membership model?
• Consider billing/collections risk: If patients lose subsidies and become uninsured or partially insured, collection risk goes up; evaluate your policy for uninsured patients.
• Consider marketing message: If affordability becomes a concern, you can emphasize cost transparency, affordable access, convenient care.
• Keep an eye on policy/insurer changes in your state: Subsidy impact varies by state (because some states have additional subsidies or Medicaid expansion differences). For example, in your state (Connecticut) the marketplace () reports many enrollees would lose subsidies.

What you should do now (and plan for)

• Stay informed: Track Congress’s action on extending subsidies (as of now, enhancements expire end of 2025).
• Scenario planning: Build financial models for your practice that assume: (a) subsidies stay (b) subsidies expire. What happens in each case re: patient volume, payer mix, bad debt?
• Engage patients/education: Have discussions with patients about their insurance coverage, premium burdens, possible changes next year — they may need to adjust their choices, and sooner you know, the better for your scheduling/planning.
• Review contracts: Especially if you participate with marketplace‐plans; see what the insurer is doing for 2026. Are they planning rates/benefits changes that will affect access to your practice?
• Consider alternative models: If you haven’t already, think about offering direct membership care, hybrid pricing, telehealth, or bundling to capture demand from cost-sensitive patients.
• Billing and collections readiness: Tighten policies for patients who may lose coverage; assess your allowance for sliding scale; possibly review charity care policy.
• Communicate with staff: Prepare your team about possible shifts in patient behavior (e.g., delayed care, insurance drop-outs) so scheduling, billing, and patient flow can adjust.

Specific relevance for NP-owned practice

Since your practice is NP-owned (likely smaller, more agile than large hospital systems), you have some advantages: you may be better able to pivot to more cost‐effective models and respond to patient affordability needs. But you also may have fewer resources to absorb sudden increases in uninsured visits or bad debt.

• Your practice may benefit from emphasizing affordability: As marketplace premiums rise, patients may look for lower cost care alternatives — your NP-led model could appeal.
• You may consider membership or subscription models: Direct primary care (DPC) or hybrid models might become more attractive to patients facing higher premiums.
• You may also need to monitor payer reimbursement trends: If insurers raise premiums because of subsidy expiration, they may also try to negotiate provider rates differently; staying aware and actively managing contracts is key.

In short: The expiration of ACA marketplace subsidies is likely to increase cost pressures for patients, which in turn can impact your practice via changes in payer mix, uninsured volume, and patient behavior. But if you anticipate and adapt, your NP-owned practice may be well-positioned to respond to those changes.

Here are several reliable sources that discuss what the expiration of the enhanced Affordable Care Act (ACA) marketplace premium tax credits (subsidies) would mean:

• The Kaiser Family Foundation (KFF) Issue Brief: “Inflation Reduction Act Health Insurance Subsidies: What is Their Impact and What Would Happen if They Expire?” — shows that if the enhanced subsidies expire at the end of 2025, almost all Marketplace enrollees would face steep increases in premium payments starting in 2026. KFF+1
• KFF’s “About Half of Adults with ACA Marketplace Coverage…” — indicates that around 48% of adults under age 65 enrolled in the individual market are either self-employed or small business owners/small business employees, meaning this change affects a lot of people in your category (NP‐owned practice serving self­employed patients). KFF
• Analysis by the Health System Tracker (via KFF) “Early indications of the impact of the enhanced premium tax credit expiration…” — estimates that expiration will result in over a 75% average increase in enrollee premium payments, and that insurers anticipate a sicker risk pool. Health System Tracker+1
• Commonwealth Fund Issue Brief: “Expiring ACA Premium Tax Credits Could Lead to Nearly 340,000 Jobs Lost Across the U.S. in 2026” — emphasises broader economic and coverage implications if the subsidies expire. Commonwealth Fund
• KFF “Who Might Lose Eligibility for ACA Marketplace Subsidies …” — shows how eligibility for subsidies would change, particularly for incomes above 400% of the Federal Poverty Level (FPL). KFF
• KFF “How Much Would People Pay in Premiums if the ACA’s Enhanced Subsidies Expired?” – interactive/analysis tool showing large increases in premium payments if the subsidies expire. KFF+1

BE INFORMED AS A BUSINESS OWNER.