Will 2026 Healthcare Costs Destroy Financial Independence for Millions?

24:18I think that there's a few things to note here is about half of people on the Affordable Care Act exchanges are associated with a small business, are gig workers. They have come to rely very heavily on this. People in occupations that we typically think of as being more in Republican areas of the country or in Republican congressional districts, farmers and ranchers, about a quarter of them receive their health coverage through the Affordable Care Act exchanges. What this underscores is that while no Republicans voted for the passage of the Affordable Care Act in 2010, their constituents and their states have really come to rely on and disproportionately benefit from the affordable care act marketplaces and the enhanced premium tax credits over the last few years.

25:01I don't understand the ins and outs of the congressional debate very well. I get the Democrats want to extend the subsidies. But my impression is, or what I believe to be true, is if you asked a right-wing person listening to BiggerPocketsMoney what the position is in a philosophical sense, it's, hey, 75 to 90%, depending on which estimate you want, of healthcare costs in the United States are related to chronic illness that are directly correlated with or related, attributable to lifestyle factors, lifestyle decisions. Is that concept being brought to the table by Republicans in this debate as part of this discussion in a way that you know of?

25:42You know, not that I've heard of. That side probably points to statistics that around 5 % of the population of the highest spenders on healthcare make up over 50 % of total healthcare spending. So those are certainly related. Any policies that have been proposed by the GOP over the last few months don't really seem to get at this underlying issue of high healthcare costs in the US.

26:08Mindy Jensen:What we're talking about are people who are already retired. So their income is actually very low compared to their net worth. Their net worth is millions of dollars, but they have the ability to manipulate their income through Roth conversions or strategic stock sales so that their income stays at or below that 400 % of the federal poverty level, ensuring that they get the full subsidy. So these subsidies weren't created for multimillionaire early retirees to have lower cost health insurance. These subsidies were created for working class Americans who don't have access to healthcare. Here's a way to be able to afford them.

26:50Mindy Jensen:I was telling the story to Scott yesterday. I remember having insurance pre-ACA and I worked for a company that didn't offer health insurance. I found an insurance broker who would be able to give me a policy. I think I was 23 at the time, she said, well, your policy, if you want to cover pregnancy is X, but your policy, if you want to exclude pregnancy is Y. And it was like$700 a month versus like 125. And I went with the no pregnancy coverage because I figured if I got pregnant, then I would just, you know, marry the guy that got me pregnant. And then I would have health insurance because That's how it worked in my mind at the time.

27:31Mindy Jensen:But I remember these, like you couldn't have preexisting conditions. So if you had a preexisting condition, it wasn't covered for the first year or it wasn't covered ever. And having things like that excluded, I mean, there are people who have, you know, asthma is a preexisting lifelong condition. You're just never going to cover my asthma. That's, you know, that's expensive. You're never going to cover any asthma related issues. So if I have to go to the hospital because I can't breathe, all of a sudden I'm footing the bill for that entire thing. And on the one hand, okay, that's kind of stinky, but that's just my lot in life.

28:06Mindy Jensen:And I just need to account for that by having a really big emergency fund. But on the other hand, having this ACA where now everything's covered and nobody can tell me, no, I'm not going to cover your asthma. You know, if you go to the hospital, we'll cover that. It's so nice to know that$15 ,000 is my out-of-pocket maximum. I mean, there's ways around that. It's really, really squidgy. You can pay more than$15 ,000 out-of-pocket, but there's now a cap. And before, there wasn't a cap. The ACA is awesome, but also these subsidies were never invented for the FIRE community. I also want to add in here that everything that we're talking about comes down to a problem that is not unique to, but is particularly acute in health insurance, which is this concept of adverse selection.

28:54A young, healthy man, for example, who is 25, 26, 27 years old, is very unlikely to need health insurance. Their costs per year for healthcare are likely to be very low, less than a thousand bucks most years. Many of them may not choose to go see the doctor. I didn't see the doctor every year when I was in my twenties on there. And so this insurance concept, for them, it's a bad bet. It's bad math. It's bad expected value math for this person in a general sense to participate in a broad plan. Age is the single biggest correlate to health insurance costs, but other things like tobacco use, chronic illness, those types of things are also major ones there.

29:31And that's the question here, right? If everybody's on their own and the market is allowed to operate independently of government oversight, then of course, health insurance pools are going to aggregate the people who are lowest risk and they're going to pay the least. And the people who are the highest risk or most likely to need health insurance are going to pull together. And that's going to be very expensive or untenable for them. And that's the challenge is how does America think about that problem here? And we can't agree as a country about what the right approach is here. I do want to get back to this question though, because that I asked earlier around this problem is going to be most acute in specific geographies over the next year, right?

30:10In Colorado, the cost for health insurance for that family of four, like I mentioned, is a thousand bucks for someone in my, my, my, my, my, my 1100 bucks or so, but in Vermont, it can be 22 to 2400 bucks for the same coverage, right? So my counterpart in Vermont, who's going through this challenge is gonna have a very different conversation. It's going to, it's going to be really hard, even if they're totally uncomfortable with going without insurance, or they're totally uncomfortable with the idea of a health share or they're totally uncomfortable with other options, they're going to consider them if their cost goes from$400 to$2 ,400 a month.

30:42And in Colorado, maybe more people are like, you know what, I don't like paying an extra$700 a month, but that's not going to completely kill my budget. Can you explain why the costs are so dramatically different across geographies in this country? Yeah, I think along with this conversation, it's good to take a step back and talk about how different insurance plans are priced in the U.S. and how that varies upon a couple different factors. So we talk about how premiums are set in the ACA marketplaces. We're really talking about the rules that insurers have to follow when they price coverage. So under the ACA, insurers cannot vary premiums based on someone's health, medical history, and they can't charge more if a person has a chronic condition.

31:22But there are a few factors that they are allowed to use, and these are ones that shape unsubsidized premiums. So the first factor is age. Insurers can charge older adults up to three times as much as younger adults. And this is one of the biggest drivers in variation in the sticker price of coverage. They can also vary based on tobacco use. So smokers can be charged up to 50 % more, although not every state follows this. Additionally, with age, different states can have different ways to rate with age. Some states don't rate at all with age, which Vermont is one of them and is one reason why when we look at an average insurance cost, Vermont might seem a little bit higher, but for 60-year-olds, they actually are going to be paying less in Vermont than they would in many other states because that's not an age rated state.

32:09Family size also matters too. A family of four pays more than an individual because each covered person is counted separately in the premium calculation. And like I said, current health status is not allowed to affect premium. Someone with diabetes or cancer pays the same premium as someone who's healthy as long as they're the same age, live in the same area, and choose the same plan. Before the ACA, some of these people may have been denied coverage, but now they have guaranteed issue to make sure that even if they're previously diagnosed, they can still be covered. Beyond these individual factors, there are market-level forces that influence how high premiums are before subsidies applied.

32:42So plans are offered in a state at the county level. So if you drive across the border to a different county in a state, that same plan may not be offered. It also could be offered but at a different price. Other factors that potentially affect the price of an unsubsidized premium is just how many insurers compete in the market. If there's more insurers, there's more competition, which is likely to drive down different premium costs. Additionally, how much providers like hospitals or physician groups charge in that region. Additionally, the overall health and size of the risk pool. A lot of states with really high premiums, think Alaska, Wyoming, West Virginia, have really small populations and thus really small populations on the Affordable Care Act marketplaces.

33:26Another factor that can affect the cost of insurance is whether states have reinsurance programs to help offset very high cost claims. So all of these together determine the full unsubsidized premium, and then we apply that federal premium tax credit that adjusts what people actually pay based on their income.

33:45Mindy Jensen:There was a penalty if you didn't have insurance. That was to encourage everybody to get on the ACA. And then the federal penalty was not removed, but it was dropped to zero. So it was removed. I don't understand why they didn't just remove it altogether, but maybe that's so they could introduce it back again if it didn't work out. But it seems like because there's no penalty to not having insurance, people can just skip the insurance or they can go, like, does a health share count as insurance for this context? Like if I opted for a health share instead of health insurance, does that count? And then I don't have to pay the penalty?

34:20I do want to chime in that there are two states that do give you a penalty if you don't have insurance, right? I think it's Massachusetts and California. Is that correct, Matt?

34:27Mindy Jensen:There's more, but it's, I mean, it's hard to find this information even with Google. Google's great, except they keep spitting out all this information that's like sort of true. I think what you're speaking to is that one of the key principles actually of the Affordable Care Act was budget neutrality through these penalties, fees, and taxes that was supposed to offset this increase in spending on premium tax credits and through the expansion of Medicaid to a population up to 138 % of the federal poverty line. These are all things that, you know, through whether it be court cases or through executive action, bringing down the penalties to zero, have just not come to pass, actually.

35:05But yes, you're correct. I don't have the states right off the top of my head, but there are some states that still require individual coverage. And there are other states that have really, they have what's called a basic health plan to try and fill the gaps of people being uninsured too. So the ACA created a lot of different flexibility at the state level to create these laboratories of experiments or whatever the term is to try different policies to fix a lot of the issues that the ACA wanted to solve. I'm going to spit out a conjecture here. You can comment on the parts that you're allowed to comment on here, Matt.

35:36I love the neutrality. America is facing a situation where about 10 % of its citizens are on a plan that's going to be impacted by the decision about how or whether to extend these enhanced subsidies. Americans pay way more than most other countries for health insurance and healthcare in a general sense. That number is growing much faster than inflation. In 2025, it's projected to increase by about 7.1 % national health expenditures to aggregate amount of money this country spends on health care. And yet that is disproportionately impacting the unsubsidized premiums for the average ACA plan participant.

36:18The cost out of pocket if no action is taken by Congress is not going to be this 26 % lift in premiums. It's going to be a well over 100 % lift for the average plan participant who is receiving a material amount of subsidies. And that problem is going to be felt disproportionately and most acutely in specific states that have whatever combination of challenges that they have that cause the premiums to be higher for individuals in that state. That can vary by your situation. But I think the bottom line from all of that is millions of Americans, tens of millions of Americans are going to be forced to do math on this subject for the first time.

36:58And it's going to be, it's a requirement because they can't afford it in the first place. And for the fire community, our privilege of being fairly wealthy is being able to do that math from an expected value perspective about how and whether to participate in this plan. And the Congressional Budget Office is suggesting that as many as 4 million people are going to shift out of these plans next year if the subsidies aren't extended. So this is not like me prophesying a doom and gloom. This is an official government body that has done the research on this is saying, no, millions of people are going to flee these plans, these ACA plans.

37:35So that brings us to the alternative. What are the alternatives today? What do these 4 million, 5 million people go to if not an ACA plan? You know, that 4 million is just people who will become uninsured. So those are people who, you know, might be disproportionately younger, healthier, relatively lower costs. They use less care in a given year, they can assume the financial risk of no longer having any health coverage. Some people, where it's likely those who are relatively older who may have a chronic condition, maybe aren't as risk or less risk averse, they may stay on the health insurance coverage and they have no other option but to just foot that extra bill and pay that extra amount.

38:20So obviously that 4 million people, there's additional people who may decide to go back to a less affordable employer option. These people also may decide to switch jobs. We know that about half of people on the Affordable Care Act marketplaces either work for a small business, own their own small business, or are self-employed in part of the gig economy. These people may decide to switch jobs, give up the small business, close its doors, give up the flexibility that comes with gig work just so that they can have an affordable employer offer. You know, this could also affect Infect occupations that we know disproportionately rely on the individual market.

38:56So we know over a quarter of farmers and ranchers receive health coverage through the Affordable Care Act marketplaces. So that could be an occupation that could be affected. And those people may switch jobs just to have an affordable employer option. A fear for farmers in this country, huh? Let me ask you this. Is KFF allowed to comment? Do you have any data? Do you have any observations at all around the alternatives to traditional health insurance that are popping up like health shares, like crowdsourced health care and those kinds of things? You know, these health shares, short term limited duration plans, commonly known as junk health plans, may be seen as a viable option because they have a lower cost premium, especially for people who don't maybe have that many health conditions.

39:42these can be really attractive, but these plans do not have the same protections as Affordable Care Act compliant plans. They are not compliant with the Affordable Care Act. And thus, if you have a pre-existing condition, anything related to that may not be covered. If you have an emergency room visit, potentially you could be footing the bill for a large portion of that. So if you're deciding that, you know, you still want some form of coverage and it's not going to be a marketplace plan, you really need to read the fine print and understand what you're signing up for because these short-term plans may not be as generous as they seem.

40:19One question I think that comes to mind, I think a lot of people have is, why aren't alternative insurance programs popping up? And I think the answer to that is federal law says there are certain rules around insurance programs, but can you give us the biggest federal law points there? I think that you talked about, you can't charge more than three times as much for older adults, for younger adults. You can't deny pre-existing conditions. There's some of those things that prevent plans of lower cost from emerging for young, healthy folks, for example. Is that true? Yeah, there's different. The Biden administration took different executive action and rulemaking to try and keep these plans siloed a little bit and make sure they are accurately representative people are signing up for them.

41:04And I think just because a lot of people want to feel really, like truly covered when they have health insurance, they go to some of these more traditional outlets to buy insurance and get a more typical health plan. I will conjecture here because I know you can't, I don't want to put you in a position, you've been wonderful with all this, thank you. And you were very clear about this is like the neutral position is wonderful on all this. But I will conjecture here, right? Let's say we don't extend these subsidies, we modify them in such a way that encourages all or much of that population of 4 million people who may leave the exchange and go uninsured here.

41:39And you see other folks moving to employer plans, or you see other folks moving to health shares or some insurance alternatives. Well, then the obvious result of that is going to be that next year, premiums go up for everybody again in a pretty disproportionate way, because the pool that's remaining is less healthy, more dependent on traditional insurance, more price inelastic, if you will, for this need that one has in life for healthcare. This is a classic insurance death spiral. So does KFF have any research on the likelihood or probabilities of insurance death spirals and how that translates to costs for Americans who do depend on the plans over the next couple of years?

42:17I would say that I don't think the marketplaces as of right now, especially with the enhanced premium tax credit, focusing just on the affordable character marketplace, is it's not in a death spiral. Certainly, if the enhanced premium tax credits do expire, then what's going to happen there is enrollees will be shed from the risk pools, and those enrollees will likely be younger, healthier, those who can assume the risk of no longer having health insurance, which leaves an underlying sicker pool of people that insurers have to cover, which will raise premiums for everyone and which will cause more people to shed off the marketplaces and so on.

42:52There will be a point of stabilization. The Congressional Budget Office is estimating that 4 million people are going to leave the marketplaces and become uninsured because of this. Their predictions of total enrollment decline is not to zero. It's to a level like just under 20 million, I think. There were premium tax credits in place before these enhanced versions of them came into place that allowed the marketplaces to grow and become stable. So we don't have any models or anything and say, you know, this is the percent chance that the ACA marketplace is going to enter a death spiral. But I would just say that the different tools that are in place right now would make that, you know, pretty unlikely.

43:32And I don't think that we'll see an entire collapse of the marketplaces if the enhanced premium tax credits do expire. Although, you know, we will see a sizable portion of the ACA marketplace pool right now become uninsured if they do expire. All right, this is our final ad break, and we'll be sharing more healthcare information after this.

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45:33Mindy Jensen:Thanks for sticking with us. So what can somebody do in the face of these rising premiums here as a consumer that is contemplating a plan on the Affordable Care Act and the exchange? And And specifically, I want to use myself and the people that are probably listening to this podcast as the example, right? People who are listening to this podcast are or intend to be multimillionaire early retirees. There's a component of self-insurance that I'm inherently comfortable with there, right? I'd be comfortable with a plan, for example, that allowed me to pay the first$10 ,000 or$25 ,000 out of pocket with no co-pays or contribution in there because I'm comfortable with that.

46:11But I cannot handle a, you know, multi-hundred thousand or multi-million dollar health insurance bill. Are there options for people like that in the marketplace today? And how should someone in that situation think about navigating the next few years? Maybe the most important thing is to, if you have an established relationship with a navigator, agent, or broker, go talk to them. They're going to understand maybe your healthcare needs or at a very minimum, be able to explain the different plan options in your area and help you choose the plan that is right for you. If you want to be protected from owing hundreds of thousands of dollars, you know, there's still a chance of that with any health issue, but I would say definitely choose an ACA compliant plan over a short-term limited duration plan.

46:55At the end of the day, people who want to stay on the Affordable Care Act marketplaces, the reality is that there's going to be no good option. They are just going to have to pay more if they want to stay on the ACA exchanges. There are some things they can do if you're at a higher metal tier plan, like a gold or silver, you can drop down to a bronze plan, which has a lower monthly premium. But the flip side of that is that you could, you know, you have now face a deductible that's, you know, thousands of dollars more on average, $7 ,000 for a bronze deductible this last year. So you could be paying more out of pocket.

47:28That means that you're paying more annually. You have a higher maximum out of pocket limit. That means that you, every time you go to a doctor, you're going to be having to pay more for a copay or coinsurance, but you just have to make sure that you have enough in savings to be able to meet these medical costs and not fall into medical debt, which is a very pervasive issue in America. It's not fun. Thank you for coming on and providing such really good information and realistic assessment of the situation here, Matt. It's not good news, but you did a wonderful job, I think, overviewing the situation and giving us a clear understanding of what's going on here, what the two political parties seem to want in this negotiation, and what it means for the average consumer who's a participant in this marketplace right now.

48:15Thank you so much. Yeah, it was a pleasure. Thank you for having me. Matt, where can people find out more about you? And can you tell us more about KFF and what you do over there? Yes. So KFF is a nonpartisan health policy information organization. I work in our policy analysis division, which provides information on different issues in health policy. I work on our Affordable Care Act team, but we have a team that works on virtually any topic in American health policy. We also do public opinion and survey research. We also do looks into health misinformation and trust on a national level. And we have a news division called KFF Health News, which partners with different local media outlets to cover different issues in different areas of the country.

49:00If you want to read more about health policy in the United States, you can go to kff.org, where you'll find all the information you could possibly ever want on U.S. health policy. It really is just absolutely incredible what you guys have put together at kff.org. And I've used a lot of those resources in the last few weeks preparing for this interview here. And, you know, to check out, you know, the calculators you have here, the data sets, the visualization, it's really world class. So thank you for what you do there. Definitely encourage folks who are curious to learn more about this and do it more self-education on the topic, go to KFF.org.

49:31It's incredible what they put out here.

49:34Mindy Jensen:All right, Matt, thank you so much for your time today. And we'll talk to you soon. Thank you. All right, Scott, that was Matt McGough from KFF. And that was wide eye-opening. Holy cow. I learned a lot talking to him and preparing for this episode. What did you think of what Matt had to say? Grief. These people from these think tanks are so good. I mean, like this is the last time we had someone that was this knowledgeable about a specific area of policy was Preston Cooper. When he talked about the ROI of college, similar kind of concept here. Man, this guy is an all-star. That was fantastic. I learned a tremendous amount on the situation.

50:06I think, unfortunately, the takeaway is plan on health care costs in the United States of America growing at a faster rate than inflation. Plan on the premium costs for ACA policies growing at much faster than that. and be prepared for the realistic possibility that policy change could impact, I think, the fire community in a particularly acute way, because I do not think the intent of the policy underlying all of this discussion is to subsidize multimillionaires who are realizing small amounts of income by withdrawing from their financial asset pool at levels below various federal poverty multiplier thresholds.

50:43I just don't think that's the intent of the policy. And I think it's a bad plan to rely on that 100%. I think people should have backup plans and really factor that into their fire decision. And I think those backup plans need to be paying much more for health insurance or taking seriously some of the non-insurance alternatives out there that can and should make you really uncomfortable, but need to have the math and the assessment and knowledge built up around them.

51:07Mindy Jensen:Yeah, I was shocked to see that it's only 10 % of Americans on the ACA, And it's an outsized portion of the fire community. But, you know, another way to phrase that is 90 percent of Americans are not insured through the ACA. That's pretty shocking to me. I don't. Did you know that before we started doing this episode, Scott? Well, I knew that from the research to prep for the episode. But, yes, that surprised me when I initially researched this is, you know, for an item that shut down the government. I think that explains why nobody knows what the hell is going on when it comes to ACA premiums in a general sense.

51:44The headlines in like the major newspapers don't seem to really explain the issue very well. We have to bring on a superstar expert from a think tank that does, you know, crazy amounts of research and data on policy analysis to even comprehend the issue and really get under underlying causes that are driving this outcome that is so acute for 30 million people, 22 million of which receive heavily subsidized ACA premiums.

52:10Mindy Jensen:There's a lot of people in the fire community who are going to have to start thinking about how they're going to handle their health insurance, but relying on ACA subsidies to help foot the bill, I don't think is a long-term solution. I think you're right, Scott. I think they need to start thinking about, I mean, it's going to be a line item in your budget, health insurance and a cost, and that cost is just going to be more. Is it a fire killer? Right. That's the question. And I think the answer is if your requirement is to have insurance and you're not comfortable with alternatives, yeah, it could be.

52:43This is a real challenge. And I think it is not appropriate to plan on them continuing in perpetuity if you're a multimillionaire at the previous rates. I think that's a bad plan.

52:53Mindy Jensen:I agree. I think it is a bad plan. And I think that you, the listener, needs to start thinking about different alternatives. I do see a scenario where healthy individuals are leaving the ACA and going into alternative health insurance. I mean, Scott, you have an alternative health insurance. I have an alternative health insurance in addition to the, what I'm calling the catastrophic plan, the HSA, the high deductible plan that I use sporadically, but not really. I use my concierge doctor service because it's cheaper. I joined a health share, right? And because I face the same problem that 22 million people in America might face if these subsidies aren't extended.

53:35I face the same problem simply by having a higher income than what would qualify for subsidies here in Colorado. So I had to do this math. And for me, I'll say it. I'm not that comfortable with the health share. I don't love being on the health share compared to an insurance policy. But the math is so absurdly better that even if I assign significant, double, triple the amount of risk for not having a serious claim subsidized by the health chair, I still come out so far ahead. It's crazy. So I'm not comfortable with it either. And I think it's a real issue that this community and the entire self-employed community in America will have to grapple with.

54:09Mindy Jensen:It is. I look forward to seeing what Congress comes up with. That'll be fascinating. And if they come up with something completely different, we'll have to bring Matt back on. All right, All right, Scott, should we get out of here? Let's do it. That wraps up this episode of the BiggerPocketsMoney podcast. He is Scott Trench. I am Mindy Jensen saying good luck, little duck. If you've been putting off life insurance, I get it. The old process was miserable. Phone calls with an agent, a nurse coming to your house for a blood draw, then waiting weeks to find out what you'd pay for. That friction is exactly why so many people who should have coverage don't.

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