By Kathy Pendergrass
In 2026, significant changes and policy uncertainties around public health insurance are likely to disrupt coverage for millions of Americans and, by extension, their ability to afford essential healthcare and medications.
Three primary developments are driving this uncertainty:
- Expiration of enhanced Affordable Care Act (ACA) Marketplace premium subsidies at the end of 2025 could result in substantial premium increases and coverage loss in 2026.
- Fewer available coverage options due to Medicare plan reductions and market exits in some regions.
- Medicaid work requirements will start affecting eligibility, risking coverage loss for many who cannot meet or document new requirements.
Coverage shifts due to these developments are likely to impact patient affordability and adherence, including a potential increase in patient assistance program (PAP) volume. By knowing what to expect, life sciences organizations can adapt their programs to address changes and support patients as they navigate new affordability hurdles.
1. Coverage Loss and Premium Increases as ACA Marketplace Subsidies Expire
The 2025 government shutdown ended without legislative agreement on extending the federal subsidies that were established in 2021 and extended through 2025. These tax credits have kept ACA Marketplace plan premiums affordable for millions, aiding 22 million out of 24 million Marketplace enrollees. Without resolution, an estimated 4 million people risk losing coverage as premiums payments more than double, increasing by an estimated 114% on average.
As of today, December 30, 2025, there is no legislative solution in place, and with Congress in recess, it is highly likely that the subsidies will expire on January 1, 2026. With heightened financial pressure, ACA enrollees may choose to forgo health insurance altogether, while patients who continue their enrollment in ACA plans could find themselves underinsured for certain therapies.
Although the tax credits are scheduled to expire on Jan. 1, lawmakers may still approve a retroactive extension in the new year. If that happens, a special enrollment period would likely allow individuals who dropped coverage due to higher costs to re-enroll at lower premiums. Until a final decision is made, many people may choose to drop their coverage for 2026, which could increase the number of uninsured individuals seeking PAP. If subsidies are later extended retroactively and individuals re-enroll in Marketplace plans, Advanced Benefit Verification checks can identify the change in coverage and transition the individual to a copay card or standard cost-sharing assistance as appropriate.
2. Medicare Plan Changes and Reduced Choices
In at least 35 states, Medicare patients had fewer plans on average to choose from for 2026 coverage than they had available to them in 2025. For 2026, major insurers like UHC, Humana, and Aetna are scaling back their Medicare Advantage (MA) presence by exiting counties or even entire states. The impact, in part due to rising costs and reduced government funding brought about by the Inflation Reduction Act (IRA), will impact hundreds of thousands. Several smaller insurers are also leaving the market entirely. Though the overall market choice for many remained relatively stable, some areas did see significant reductions that required affected members to choose new plans during the past enrollment period.
These effects can further erode medication adherence and treatment continuity, especially for complex or high-cost therapies. To identify changes, AssistRx has provided a detailed list of Medicare plan exits by market and re-enrollment scenarios for patients navigating plan options.
3. Risk of Losing Medicaid Coverage Due to Work Requirements
The 2025 budget reconciliation bill (H.R. 1), commonly referred to as the “One Big Beautiful Bill Act” (OBBBA) and signed into law on July 4, 2025, introduced mandatory work requirements, or community engagement requirements, for non-disabled Medicaid enrollees ages 19-64. The new work criteria for Medicaid eligibility are being implemented in certain states beginning in 2026. Under the federally mandated requirements, enrollees must complete and document at least 80 hours per month of work, education or community service to maintain coverage. Exemptions exist for disability, caregiving duties and student status, and states must review eligibility every six months.
These work requirements could result in a loss of coverage for those who are unable to meet them or prove exemption. Others could risk coverage loss due to the administrative burden of documenting activities. Loss of Medicaid often means losing access to stable care and affordable prescriptions, especially for patients with chronic conditions or high medication costs.
Considerations for Life Sciences Organizations
The convergence of the imminent expiration of enhanced ACA subsidies, Medicare participation shifts and Medicaid policy changes creates significant risk for patient access to coverage and medications in 2026. Recognizing and responding to these trends will be important to treatment continuity and ultimately the health of the patients who depend on therapy.
Rising costs and plan changes will likely increase patient reliance on PAPs to maintain therapy access. Life science organizations will need partners capable of scaling PAP operations, rapidly adapting program eligibility and navigating complex affordability pathways to prevent therapy disruption.
AssistRx tech-enabled patient support programs combine tech and talent to deliver advanced access, affordability, adherence and analytics solutions. Our technology can confirm eligibility for PAPs in real time while our expert teams support coverage continuity through alternative coverage research.
Advanced Insurance Assistance (AIA)
AIA provides hands-on support to help patients and their families find and maintain the best available health coverage, whether through commercial plans, Medicare, Medicaid or the Health Insurance Marketplace options, at no cost to the patient. Our expert patient insurance navigators guide patients through plan comparison, selection and enrollment, helping them identify plans that balance affordability and quality without disrupting continuity of care.
Application: AIA experts help ensure complete and accurate submissions the first time, reducing delays, maximizing approval rates and safeguarding patient access. If patients face financial difficulty due to rising premiums or are rendered underinsured for certain therapies, our teams guide them through their options based on a holistic financial assessment (e.g., all prescribed medications, household income, assets).
Comprehensive PAP Offerings
AssistRx solutions ensure eligible patients continue to access their prescribed therapies through real-time screening and approval through our ePatient Assistance Program (ePAP) offering and rapid free-drug fulfillment through our non-commercial specialty pharmacy. By providing both ePAP and non-commercial specialty pharmacy services, AssistRx delivers efficiencies with native integrations, an expert single point of contact with a 365-degree view of the program, and holistic reporting on program performance.
Application: For patients losing financial support or those unable to afford medications due to rising premiums and/or coverage changes, AssistRx delivers comprehensive PAPs through a configurable design that rapidly adjusts eligibility criteria and scales support to sustain therapy access.
The AssistRx Difference
AssistRx remains dedicated to patient care and is committed to helping life sciences organizations navigate these evolving conditions to ensure patient access. Through real-time insights, adaptable program models and integrated access and affordability solutions, we help ensure therapy access and patient support continue uninterrupted.
Stay informed with the latest updates and guidance by connecting with our team.
Sources:
Bonavitacola, J. (2025, November 4). Medicaid work requirements set to leave millions without insurance. The American Journal of Managed Care. https://www.ajmc.com/view/medicaid-work-requirements-set-to-leave-millions-without-insurance
Steinzor, P. (2025, October 31). 5 consequences if ACA premium subsidies end in 2026. The American Journal of Managed Care. https://www.ajmc.com/view/5-consequences-if-aca-premium-subsidies-end-in-2026
Kaiser Family Foundation. (2025). ACA marketplace premium payments would more than double on average next year if enhanced premium tax credits expire. https://www.kff.org/affordable-care-act/aca-marketplace-premium-payments-would-more-than-double-on-average-next-year-if-enhanced-premium-tax-credits-expire/
Niasse, A., & Aboulenein, A. (2025, December 18). Americans facing soaring health insurance costs may get lifeline in 2026, experts say. Reuters. https://www.reuters.com/legal/litigation/americans-facing-soaring-health-insurance-costs-may-get-lifeline-2026-experts-2025-12-18/
Strock, J. (2025, October 23). 2026 MA market exits: Which companies are out & what it means for key states. Medicare Market Insights. https://www.medicaremarketinsights.com/p/2026-ma-market-exits-which-companies-are-out-what-it-means-for-key-states
Kaiser Family Foundation. (2025). Medicare Advantage 2026 spotlight: A first look at plan offerings. https://www.kff.org/medicare/medicare-advantage-2026-spotlight-a-first-look-at-plan-offerings/
About the Author
Kathy Pendergrass is an experienced Medicare advisor with 20 years in healthcare and 14 years in the pharmaceutical industry, with expertise helping individuals navigate the complexities of Medicare and related health insurance options. As Developer and Program Manager of AssistRx’s Advanced Insurance Assistance (AIA) solution, Pendergrass is the Subject Matter Expert (SME) regarding coverage, pharmacy relations, patient access, financial assistance across diverse disease states and regulatory developments.