Within the next 90 days, the 24 million enrollees in Affordable Care Act (ACA) health insurance exchanges will get notices about massive new cost burdens to renew their coverage. This will be perceived as a direct result of the policies of the Trump administration and congressional Republicans. That perception has the benefit of being accurate.

The combination of the One Big Beautiful Bill Act’s (OBBBA) cuts to Medicaid (and, unless Congress does something about it, to Medicare) and the failure to extend enhanced ACA tax credits for exchange participants will cause roughly 15 million Americans to lose their health insurance, according to the latest estimates. Those who hang on to pay the higher rates are disproportionately likely to really need insurance due to medical conditions. This will tend to create sicker insurance pools, meaning more claims payouts by insurers.

The expectation of higher costs for insured customers, along with the pullback of trillions of dollars from the health system, has triggered insurers’ need for higher premium rates, in a kind of upward death spiral. Those who remain insured may have to choose between staying covered and other critical items in their family budgets.

“I don’t think many members of Congress have yet focused on these big health insurance premium increases coming,” said Larry Levitt, executive vice president for health policy at KFF. “When they do, especially for Republicans, it may make them nervous at the prospect of going before voters right after many of their constituents have been hit with big premium increases.”

An analysis of proposed premium changes for 2026 submitted by health insurers this spring and summer reveals the largest rate hikes since 2018, which were also driven by disruptive conservative changes, like the active attempt to repeal the ACA entirely. More than one-quarter of all insurers are requesting increases above 20 percent, and only five of the 105 exchange insurers are seeking increases below 5 percent. The median increase is around 15 percent, more than double the median increase of one year ago and more than double the underlying increase in the cost of medical care.