The 2026 Affordable Care Act (ACA) open enrolment period has ended with fewer Americans signing up for coverage, and in San Francisco and the wider Bay Area the financial impact is already being felt. Thousands of local households are now facing sharply higher monthly health insurance bills after enhanced federal subsidies expired at the start of the year.

According to new federal figures released by the Centers for Medicare & Medicaid Services (CMS), 22.8 million people selected ACA insurance plans for 2026, down from 24.2 million in 2025. The drop of roughly 1.4 million enrolleesfollows the end of pandemic-era financial assistance that had previously helped millions afford coverage. This is reported by San Francisco Newsroom, citing official CMS data, Congressional Budget Office forecasts, and analysis from KFF and ABC News.

The figures, which include sign-ups through Healthcare.gov and state-run marketplaces, show that rising premiums are pushing many families beyond the limits of affordability. In California, where residents use the state marketplace Covered California, the increases are particularly noticeable because Bay Area insurance costs are among the highest in the United States. The enrolment deadline in most U.S. states was 15 January 2026, although California and a small number of other states have extended sign-ups until the end of the month.

At the centre of the issue is the sharp rise in the price of monthly ACA insurance premiums. Independent analysis from the health policy group KFF estimates that average premiums could increase by as much as 114% in 2026 for people who no longer qualify for government support. For many San Francisco families, that means thousands of dollars in additional annual costs. As the political battle over subsidies continues in Washington, experts warn that the changes could leave large numbers of Americans uninsured or forced to choose lower-quality alternatives.

Why are ACA insurance premiums rising so sharply in 2026

The main reason for the price shock is the expiration of enhanced premium tax credits introduced during the COVID-19 pandemic. These credits reduced monthly costs for millions of Americans and expanded eligibility to many middle-income households. When those measures ended on 1 January 2026, the full underlying cost of plans was once again passed on to consumers.

Key factors behind the increase

• End of enhanced pandemic-era subsidies
• Rising healthcare and hospital costs
• Higher prescription drug prices
• Increased demand for medical services
• General inflation across the U.S. economy

The Congressional Budget Office (CBO) has estimated that benchmark ACA premiums could rise by 4.3% in 2026 and by 7.7% in 2027 even before individual subsidy changes are taken into account. For households that lose subsidies entirely, the real-world impact is far more dramatic.

How many people have enrolled in ACA insurance this year

Source: Centers for Medicare & Medicaid Services

The data shows that 2025 represented a peak year for ACA participation. The reduction in 2026 marks the first major decline since the pandemic. Officials expect enrolment to fall further as more people receive premium bills reflecting the full unsubsidised price.

Who is most affected by the ACA insurance changes

The 2026 changes are not affecting all Americans equally. Federal data and independent analysis show that costs are rising most sharply for middle-income households that previously relied on subsidies.

Those hardest hit include:

• Individuals earning more than 400% of the federal poverty level
• Older adults approaching retirement age
• Self-employed workers and freelancers
• Small business owners
• Families without employer-provided coverage

Under current rules, anyone earning above the subsidy threshold loses access to financial assistance entirely.

For 2026, that threshold is:

• $62,600 for an individual
• $84,600 for a couple

Example of real-world impact

KFF estimates that a 60-year-old couple earning $85,000 could see their annual ACA insurance costs rise by $24,600 in 2026. For many Bay Area residents, where living costs are already high, these increases are proving particularly difficult to manage.

What are short-term health insurance plans and why are people switching

As premiums rise, some Americans are turning to short-term health plans that operate outside ACA rules. These plans are often far cheaper – sometimes as low as $70 per month – but they come with serious limitations.

Differences between ACA and short-term plans

Michelle Long, senior policy manager at KFF, warns consumers to be careful:

“There are some unscrupulous actors out there who present plans that seem to be ACA-compliant but are not,” she said in comments to ABC News (January 2026).

What is happening politically with ACA insurance subsidies

The future of ACA insurance subsidies is locked in a political standoff in Washington. Enhanced premium tax credits expired on 1 January 2026, triggering sharp premium increases for millions of Americans, including thousands of households in San Francisco and California. The U.S. House of Representatives has passed a bill to extend the subsidies for three years, but the Senate has not approved the measure, and President Donald Trump has indicated he may veto any extension. Until the dispute is resolved, consumers must make coverage decisions without knowing whether financial assistance will return. The future of subsidies has become a major political battleground in Washington.

• The U.S. House of Representatives has passed a bill to extend subsidies for three more years
• The Senate has not yet approved the measure
• President Donald Trump has indicated he may veto an extension

During the recent U.S. government shutdown, Democrats pushed to include subsidy extensions in the funding bill, but Republicans refused. As a result, millions of Americans are currently making insurance decisions without knowing whether financial support will return.

How can consumers reduce their ACA insurance costs

Financial advisers suggest several legal strategies:

• Reducing taxable income to fall below subsidy thresholds
• Using deductions such as retirement contributions
• Claiming self-employed health insurance deductions
• Adjusting freelance income
• Contributing to Health Savings Accounts

Small income adjustments can make a significant difference. For example, a 60-year-old earning $64,000 could pay $14,931 annually for ACA insurance, while someone earning $62,000 would pay only $6,175.

What should San Francisco residents do now about ACA insurance in 2026

For households in San Francisco and the wider Bay Area, the 2026 ACA changes require immediate and careful action. California operates its own marketplace, Covered California, which offers additional state-level subsidies and protections that do not exist in many other parts of the country.

Practical steps recommended by California specialists

• Check plans on Covered California first, as state programmes may reduce costs
• Compare regional insurer networks such as Kaiser Permanente, Blue Shield of California and Anthem
• Avoid short-term plans unless every exclusion is fully understood
• Use free enrolment counsellors in San Francisco
• Speak with a licensed California insurance broker
• Review income forecasts for 2026, as small changes can restore subsidies
• Consider Medi-Cal eligibility, especially for freelancers
• Monitor developments in Sacramento and Washington

San Francisco has some of the highest healthcare costs in the United States, making accurate plan selection especially important.

Where to get help in San Francisco

As the political debate continues, San Francisco households must navigate rising insurance costs with limited time and complex choices. Careful planning and use of local assistance programmes can make the difference between affordable coverage and going uninsured in 2026.

San Francisco News keeps the city, the Bay Area and the wider world informed — with clear, useful reporting on what’s happening, where it matters and what people need to know across technology, business and public life. Read also: San Francisco 2026 visas: H-1B, O-1, startup visas and legal pathways to California