Don't get hurt. Don't get sick. Because you can't afford that.
For eleven years, families like the Tobiassens of Sugar Grove, North Carolina built their working lives around the quiet assurance that affordable health coverage would catch them if they fell. When Congress allowed the enhanced subsidies that had made that assurance possible to expire at the end of 2025, premiums surged beyond reach for hundreds of thousands of Americans — and the safety net they had trusted simply disappeared. What follows is not merely a policy adjustment but a reckoning with how fragile the architecture of ordinary life can be, and how quickly a market built on shared risk can begin to unravel when the healthiest among us can no longer afford to stay.
- Premiums for some families quadrupled overnight — the Tobiassens watched their monthly cost jump from $130 to over $550, forcing them to cancel coverage they had carried for more than a decade.
- North Carolina alone lost over 213,000 insured residents in a single enrollment cycle, the steepest drop in the nation, as gig workers, artists, and the chronically ill quietly disappeared from the insurance rolls.
- Without coverage, people are making impossible calculations — one man chose a nerve-killing procedure over a $30,000 cornea surgery, then returned to working with dangerous machinery half-blind.
- Healthcare researchers warn the departures are triggering a 'death spiral': as healthier people exit, premiums rise for those who remain, which drives more people out, accelerating the collapse.
- Enrollment projections suggest the ACA market could shed more than five million participants by the end of 2026, threatening the stability of a system that once covered 24 million Americans.
- Families who drop out have no clear path back — the Tobiassens explored alternatives and found none, leaving them to work and hope that nothing goes wrong.
In Sugar Grove, North Carolina, Ross and Rebecca Tobiassen run an auto shop together — demanding, sometimes dangerous work that once felt manageable because they had health insurance. For eleven years they had relied on federally subsidized ACA coverage to absorb the risks of their lives. Then Rebecca checked their upcoming premiums and found they were about to rise from $130 to more than $550 a month. They canceled their coverage. "It makes no sense," she said. "It's not worth it anymore."
The Tobiassens are among hundreds of thousands of Americans who have left the ACA marketplace since Congress allowed the enhanced tax credits — created during the pandemic under the American Rescue Plan — to expire at the end of 2025. Those credits had transformed the insurance landscape, doubling enrollment to roughly 24 million people by making premiums workable for ordinary families. Their expiration has sent the market into sharp retreat. Analysts project enrollment could fall from 22 million to as low as 16.5 million by 2026.
North Carolina has absorbed the hardest blow, with individual ACA signups falling 22 percent — more than any other state. At Pisgah Legal Services, a nonprofit helping low-income residents navigate coverage options in western North Carolina, coordinator Katie Alexander said she had never seen a year like this one. Nearly 100 of her roughly 700 open-enrollment clients chose to drop coverage entirely. The people making these choices are Lyft drivers, artists, part-time workers managing chronic illness, and small business owners — people whose employers offer no insurance and who earn too much for Medicaid. "Even for folks who don't have chronic illnesses," Alexander said, "there's just this nagging at the back of your mind: 'Don't get hurt. Don't get sick.'"
The Tobiassens had already been making concessions for years, sliding from a silver plan to the cheapest bronze option available. Even that became too much. Five years ago, when Ross's eye infection worsened, a specialist quoted him up to $30,000 for cornea replacement surgery and six months away from work. He chose a cheaper procedure to kill the nerves instead. Now uninsured, the couple has set aside some savings for emergencies — and beyond that, only credit cards and family.
Healthcare policy researcher Risha Gidwani warns that stories like theirs carry a systemic consequence. When healthier people exit the insurance pool, the remaining enrollees — who tend to be sicker — cost more to cover, pushing premiums higher and driving still more people out. "That becomes what we call a death spiral," she said. It is a self-reinforcing collapse, and it is already in motion. The Tobiassens, for their part, have no plans to return to the marketplace. For now, they work and hope nothing happens.
In Sugar Grove, North Carolina, Ross Tobiassen works long hours at the auto shop he and his wife Rebecca own, sometimes late into the night. The work is dangerous—a spring once shot a metal ball joint across their garage wall like a projectile, and years of metal shards have left him mostly blind in one eye. For eleven years, the couple had relied on federally subsidized health insurance through the Affordable Care Act to manage the risks of their lives. Then in December, when Rebecca saw their monthly premiums were about to jump from $130 to more than $550, they made a decision that terrified them: they canceled their coverage.
"It makes no sense," Rebecca said. "It's not worth it anymore." The Tobiassens are among hundreds of thousands of Americans who have dropped ACA coverage after Congress allowed the enhanced tax credits that had made insurance affordable to expire at the end of 2025. Those credits, created during the pandemic as part of the Biden administration's American Rescue Plan, had transformed the insurance market—they doubled ACA enrollment to roughly 24 million people by making premiums manageable for working families. Now that they're gone, the market is contracting sharply. An early analysis from KFF, drawing on research from Wakely Consulting Group, projects enrollment could fall from over 22 million at the end of 2025 to as low as 16.5 million in 2026.
North Carolina has been hit hardest. Individual ACA signups for 2026 dropped 22 percent compared with the previous year—a steeper decline than any other state—representing a loss of more than 213,000 people. Katie Alexander, who oversees volunteers at Pisgah Legal Services, a nonprofit helping low-income people in western North Carolina secure health insurance, said she has never seen anything like this year. Nearly 100 of her organization's roughly 700 clients during open enrollment decided to drop coverage entirely, while many others switched to cheaper plans with less protection. The people making these choices are Lyft and Uber drivers trying to start their own businesses, artists, people working part-time because of chronic illness, and workers whose employers don't offer insurance or who earn too much to qualify for Medicaid. "Even for folks who don't have chronic illnesses," Alexander said, "there's just this nagging at the back of your mind, kind of constantly, of: 'Don't get hurt. Don't get sick. Because you can't afford that.'"
The Tobiassens have watched premiums and deductibles climb for years. When they first enrolled in 2014, they paid about $30 a month. "You actually felt like you were benefiting," Rebecca recalled. But as the marketplace grew more expensive, they made concessions—switching from a silver plan to a bronze, the cheapest option available. Even that became unsustainable. The couple's insurance had never fully covered their medical needs. Five years ago, when Ross's eye infection worsened, a specialist told him that cornea replacement surgery would cost up to $30,000 and require six months away from work. Ross chose a less expensive treatment to kill the nerves in the eye instead. Now, without insurance, they have set aside some money for a medical emergency. If that runs out, Rebecca said, they have only credit cards and family members to fall back on.
Risha Gidwani, a healthcare policy researcher at the University of Colorado Anschutz School of Medicine, has studied what happens when people like the Tobiassens leave the insurance pool. Most bronze plans, the cheapest ACA options, would be unaffordable without subsidies for the average person, her research shows. When healthier people drop out, fewer people are left to subsidize those who get sick, which means premiums for the remaining enrollees will rise again. "That becomes what we call a death spiral," Gidwani said. It's a self-reinforcing cycle: as premiums climb, more people leave, which makes premiums climb further. The irony is that even if the subsidies had continued, taxpayers would have borne an estimated $350 billion burden over the next decade to cover them. The Tobiassens, after dropping coverage they'd relied on for eleven years, have no plans to return to the ACA marketplace. They looked into alternative options through a faith-based healthcare organization but decided to go without. For now, they work and hope nothing happens.
Citações Notáveis
Plans are unaffordable, no matter how you cut it. It's just who is shouldering the unaffordability.— Risha Gidwani, healthcare policy researcher at University of Colorado Anschutz School of Medicine
That becomes what we call a death spiral.— Risha Gidwani, on what happens when healthier people drop out of the insurance pool
A Conversa do Hearth Outra perspectiva sobre a história
Why did the Tobiassens stay with ACA coverage for so long if it was always getting more expensive?
Because for a long time, even as costs rose, the subsidies made it feel manageable—like they were actually getting something for their money. The peace of mind mattered. But there's a breaking point. When your premium quadruples in a single year, the math stops working, especially when you own a small business with no other safety net.
The story mentions Ross's eye injury and the surgery he couldn't afford. Does he worry about working without insurance now?
He says he tries not to think about it too much. He just works. But that's the thing—he has to work, because he has no other choice. The danger is still there. The machinery is still there. The only difference is now there's no insurance to catch him if something goes wrong.
What does Katie Alexander mean when she says people are making these choices? It sounds like they have no choice at all.
That's the paradox. Technically they're choosing to drop coverage. But the choice is really between paying $550 a month for insurance or eating, paying rent, keeping the business open. It's not a choice in any meaningful sense. It's a forced hand.
The article mentions a "death spiral." How does that actually work?
Imagine the insurance pool as a boat. Healthier people jump out because premiums are too high. That makes the boat heavier relative to its buoyancy—sicker people are left behind. So the insurance company raises premiums to cover the sicker pool. That makes more people jump out. The boat sinks faster and faster.
Is there any way out of this for families like the Tobiassens?
Not that they can see. They looked at faith-based alternatives and decided against them. They're not going back to the ACA marketplace. They're just hoping nothing catastrophic happens. That's their plan.