Trump-Era Policies Drive Rising ACA Marketplace Premiums, Burden Rural Residents

A recent analysis by the Century Foundation highlights that policies from the Trump administration are set to significantly increase healthcare coverage costs for individuals purchasing plans through health insurance marketplaces, with rural residents facing the steepest rises. The report emphasizes that the expiration of Biden-era tax credits at the end of the year, coupled with other regulatory changes, will drive out-of-pocket premiums up by an average of 93% in the 32 states using federally-operated ACA marketplaces. Rural counties are expected to see a 107% increase, compared to 89% in urban areas.

The analysis further notes that insurers have proposed a median premium increase of 18% for 2026, marking the largest single-year hike since 2018 and compounding the financial burden resulting from the tax credit expirations and other policy shifts. Approximately 2.8 million marketplace enrollees reside in rural counties within these states, including vulnerable populations such as older adults and children, who typically have greater healthcare needs.

Rural residents tend to be older and have higher rates of chronic illness, factors that inherently raise healthcare costs. The Century Foundation projects an average annual premium increase of $760 for rural enrollees, which is 28% higher than the anticipated increase in urban areas. States including Wyoming, Alaska, and Illinois are forecasted to see the highest premium increases in rural areas.

The report also connects coverage challenges to states’ decisions on Medicaid expansion, noting many with large rural populations have declined expansion under the ACA. Consequently, many low-income residents rely on marketplace plans, intensifying the impact of rising premiums. Only Nebraska and North Carolina among states with significant rural marketplace enrollment have expanded Medicaid.

Officials in some states, such as Pennsylvania, are advising residents to carefully review their marketplace options due to these rising costs. The analysis warns that these premium hikes could result in increased uninsured rates, negatively affecting individual health outcomes, healthcare providers, and overall societal costs due to delayed or inadequate care.