When Noah Hulsman, who owns a skate shop in Louisville, Kentucky, learned he no longer qualified for federal subsidies to help him pay for his “gold” Affordable Care Act health plan, the 37-year-old opted for skimpier coverage. But the deductible is about a quarter of his yearly income.

Loretta Forbes realized she would have to drop her plan after her monthly ACA marketplace premiums jumped tenfold in 2026. So the 56-year-old, who lives outside Nashville, Tennessee, started rationing her rheumatoid arthritis medications. Her husband, Jim, gave up on his fledgling handyman business and started looking for a job with insurance coverage.

And when Nicole Wipp learned the monthly premium for her family’s ACA plan would be more than their mortgage payment, she and her husband decided to drop their family plan and buy coverage only for their 15-year-old son.

After crunching the numbers, Wipp, 54, a self-employed lawyer in Aiken, South Carolina, said she and her family made the tough call.

“We decided that, ultimately, it would be better for us to gamble.”

Despite a contentious back-and-forth and the longest government shutdown in history last fall, the GOP-led Congress allowed enhanced ACA subsidies, which had helped millions of Americans cover all or part of their marketplace premiums since 2021, to expire on Dec. 31. With the loss of the subsidies and health care costs already surging, more middle-income people face tough decisions about their health coverage this year.

Hulsman, Forbes, and Wipp don’t qualify for Medicaid, the public insurance program for those with low incomes or disabilities. But like many others, they are being squeezed by the increasing costs of groceries, housing, and other necessities. Rising monthly health insurance premiums, along with copayments, high deductibles, and other out-of-pocket medical costs, can often push families like these to the brink.

More than 80% of Americans said their cost of living has increased in the past year, according to a January poll from KFF, a health information nonprofit that includes KFF Health News. Health care costs ranked at the top of their concerns, with about two-thirds saying that they are somewhat or very worried about affording health care — more than said the same about other necessities, such as food and housing, the poll found.

“Premiums are getting quite unaffordable for a lot of people. The cost of both health care and other basic needs is rising,” said Cheryl Fish-Parcham, director of private coverage at the health consumer group Families USA. “This is an especially critical time for Congress to do something.”

Most Republican lawmakers have refused to renew the enhanced subsidies. Most of the public says that inaction by Congress was the “wrong thing,” according to the KFF poll. Instead, GOP lawmakers have advocated for an expansion of health savings accounts and for more plans with lower premiums and steeper deductibles and copays that don’t reduce overall costs.

President Donald Trump released an outline of a health plan in January with few details about how to lower out-of-pocket costs for millions of Americans. The One Big Beautiful Bill Act, which he signed in July, is expected to leave millions uninsured over the next decade as it reduces federal health spending by nearly $1 trillion, mostly from Medicaid.

Already about 1.2 million fewer people have signed up for plans for this year under the ACA, also known as Obamacare, according to federal data. Health policy analysts expect more people to stop making payments and drop coverage in the coming months. ACA marketplace insurers have said that they are charging 4 percentage points more in 2026 because they expect healthier people to drop plans as enhanced tax credits expire, leaving more sick and high-cost patients.

Rising costs and lack of congressional action are forcing many to make “untenable choices,” said Joan Alker, executive director and co-founder of the Center for Children and Families at Georgetown University.

“People are faced with absorbing this huge financial and health risk,” she said.

Forbes, the woman with rheumatoid arthritis near Nashville, had been on an ACA marketplace plan since 2018. But this year she and her husband, Jim, dropped their coverage after learning the monthly premium would jump from $250 to $2,500 because the enhanced subsidies expired. Jim, 59, gave up his handyman business and began searching for a job with health insurance.

“We were like: ‘OK, we can’t breathe. We’re gonna tap out,’” said Forbes, who was diagnosed with cervical cancer in 2021. Last year she lost her job at a retirement facility because she couldn’t work after she had a hysterectomy.

A day before their ACA coverage lapsed, her husband got a job offer at a property management company that provides health coverage. In January, they learned that Forbes was approved for Medicare because of her disability. The $155 monthly premium is automatically deducted from her disability check, she said.

Forbes’ Medicare plan starts in February, just in time for her next cancer screening.

“You cannot imagine what a relief it is to know I will have care,” Forbes said.

Even those who are insured face drastically higher out-of-pocket costs. This year, health insurers’ premiums for ACA marketplace plans jumped an average of 26%, the result of higher hospital costs, the popularity of pricey GLP-1 drugs for obesity and diabetes, and the threat of tariffs, according to KFF. Nearly 4 in 10 adults said they were skipping or postponing necessary care because of costs, a 2025 KFF poll showed.

Hulsman, the Louisville shop owner, said he takes home about $33,000 a year from his business. Last year he paid about $105 a month for a gold plan on the marketplace, with a $750 deductible. This year, with the loss of the enhanced subsidy, Hulsman is paying the same monthly premium for a “bronze” plan, but with a deductible of $8,450, which he must pay out-of-pocket before his insurer starts paying for care. On average, deductibles for bronze plans are more than four times those of gold plans, according to a KFF analysis of 2026 marketplace plans.

Hulsman didn’t consider dropping health insurance, because Kentucky has limited consumer protections for medical debt. But he said he’ll try to get an estimate if he needs to go to a doctor. And he’s worried that a major accident could wipe out his skate shop. He won’t be able to buy inventory or pay shop bills if he has to meet his full deductible, he said.

“I’m just riding the line right now,” the skateboarder said. “One slip and it’s gonna be uncomfortable.”

In South Carolina, Wipp dragged her family to get routine vaccinations on New Year’s Eve — the last day that she and her husband had health coverage.

This year’s monthly premium for a bare-bones bronze family plan would have cost them $1,400, up from $900 last year. They would still have faced high copays for doctor visits and need to meet a deductible of more than $10,000. Instead, they’re paying around $200 to cover just her son.

Wipp, who has a rare condition that causes cysts and other growths to form in the lungs, said she and her husband plan to pay out-of-pocket this year for any initial preventive care. Their second source of money, for larger medical expenses, is an old health savings account. But she said that account doesn’t have enough to cover a major accident or illness. And Wipp can’t add to the account while she is uninsured.

“The third source would be, I don’t know,” Wipp said. “The fourth is bankruptcy.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact KFF Health News and share your story.

Health policy changes in Washington will ripple through the country, resulting in millions of Americans losing their Medicaid or Affordable Care Act coverage. But there are still ways to find care.

Over the next decade, the GOP’s One Big Beautiful Bill Act is expected to slash nearly $1 trillion in spending from Medicaid, the state-federal program for people with low incomes and disabilities. The implementation of new work rules will cause some beneficiaries to lose their Medicaid coverage.

Millions of Americans are facing enormous increases in their out-of-pocket costs for ACA coverage. So far, 1.2 million fewer people have signed up for Obamacare plans compared with last year, and health policy analysts estimate more will lose coverage as they fail to pay their premiums.

Health costs are a top concern for Americans. Two-thirds of the public say they are somewhat or very worried about affording health care, more than express the same worries about utilities, food, housing, or gas, according to a January poll from KFF, a health information nonprofit that includes KFF Health News.

“All of this pain just doesn’t have to be there,” said Cheryl Fish-Parcham, director of private coverage at the health consumer group Families USA.

Doctors and health policy researchers say health coverage, of any kind, is the best protection against major medical debt.

Caitlin Donovan, a senior director at the Patient Advocate Foundation, recommends exhausting every available option for health coverage before going uninsured.

Even a high-deductible plan can protect patients from medical bankruptcy “if the absolute worst-case scenario happens,” she said.

Here are five ways that the uninsured can find affordable care.

1. Don’t be afraid to talk with your doctor about money

Patients can be hesitant to tell their doctors they’re uninsured or be wary of expressing concern about being able to afford care.

But some hospitals, physicians, and other providers offer cheaper cash pay options, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at KFF.

Often prices are negotiable. “Always ask,” she said.

Health care providers can make adjustments if they know patients are worried about money, said Ateev Mehrotra, a doctor and researcher at Brown University.

“If my patient tells me, ‘Doc, I’m gonna have to pay for this out-of-pocket,’ I’m gonna make a different risk calculus,” Mehrotra said.

That doesn’t mean a patient won’t get the care they need, he said. A doctor, for instance, might order an ultrasound instead of an MRI, which is more expensive.

2. Search for providers that specifically work with uninsured patients

If your usual provider won’t budge on prices, then search for providers that cater to patients without insurance.

Federally qualified health centers, or FQHCs, and other community clinics offer routine and non-emergency care, such as treatment for flu or infection, for low-income residents and the uninsured. Community health centers charge based on a sliding scale and see 52 million patients annually in some of the country’s most underserved areas, according to the National Association of Community Health Centers.

The Trump administration has made funding cuts that might lead some of the country’s approximately 1,500 FQHCs to close or cut services. But the administration still maintains a site to find a local center.

Planned Parenthood also accepts uninsured patients. Its centers test for sexually transmitted diseases, provide birth control options, and offer postpartum and gender-affirming care and other services.

And the National Association of Free & Charitable Clinics also offers a tool to help people find free or low-cost care.

Most community clinics don’t offer specialty care, but they can usually refer patients who need more intensive services to providers willing to work with uninsured patients.

And academic medical centers tend to have more charity care programs that help uninsured patients lower their bills.

“If you’re uninsured or even underinsured, you might be able to qualify for a significant discount on the cost of your care,” Cox said.

Still, be wary of heading to the emergency room, which is the most expensive place to get care. While ERs are federally required to stabilize all patients regardless of their ability to pay, they can still leave you with a big bill — and often do.

3. Call your local health department

Health services vary widely from county to county, but many offer free vaccinations, family planning services, and testing for sexually transmitted infections, as well as for flu, covid, and tuberculosis.

Some county health departments also offer more advanced care, such as dental services and mental health or substance abuse programs. And some states have consumer assistance programs that can guide residents in finding care, Fish-Parcham said.

In addition, the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program makes free or low-cost breast and cervical cancer screenings available to low-income women in all states and territories. And some states cover screenings for other types of cancer as well.

4. It’s easier to shop around for drugs than doctors

Don’t just fill your prescription at the closest pharmacy. Instead, research generic drug options and look around for the best price on brand names.

A handful of sites such as GoodRx and WellRx offer comparison shopping tools and information on other ways to get drug discounts.

And some retailers offer low-cost access to common prescription drugs — at prices cheaper than you would find if you had insurance. Walmart, for instance, sells 90-day prescriptions of dozens of generic versions of drugs for $10. As does Target, Costco, and a new site called the Cost Plus Drug Company.

Many drugmakers also offer patient assistance programs, coupons, and rebates on some medications. Check their websites for details on how to apply.

States also offer drug assistance programs. The steps to qualify and types of drugs vary, but this tool has a list of programs and how they work.

Joining a clinical trial is another way to access treatment. The National Institutes of Health and its National Cancer Institute have lists, but patients must first meet the criteria. Clinical trials aren’t necessarily free, even with insurance, Donovan said, so be sure to ask about any associated costs.

5. Your diagnosis might lead you to specialized resources

Patients with a specific diagnosis might have additional options for specialty treatment.

For example, someone with breast cancer should check with the American Cancer Society and the nonprofit Susan G. Komen organization, Cox said.

The Patient Advocate Foundation hosts a list of vetted foundations that can help offset the cost of medical bills and provide other resources such as transportation and lodging, Donovan said. Just type in basic information such as age, location, and diagnosis to see what is available.

Disease-specific foundations such as those for lupus or irritable bowel syndrome can also steer patients to free or low-cost resources or cover some costs of care, Donovan said.

“Everything is out there,” she said.

As you research affordable care options, don’t be tricked by plans that look like health insurance but don’t offer guaranteed protection against big bills.

Some short-term plans and health care sharing ministries might seem like good deals, but read the fine print. Some red flags to look for: too-good-to-be-true monthly payments; no coverage for preexisting conditions; morality clauses such as those prohibiting the use of alcohol or drugs; or a lack of coverage for benefits such as mental health counseling that are required in ACA plans.

KFF Health News correspondent Sam Whitehead contributed to this report.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact KFF Health News and share your story.