Open enrollment is under way for 2026 insurance coverage, and millions of Americans are facing extreme sticker shock thanks to the end of expanded Affordable Care Act subsidies, which capped Obamacare premiums for a “benchmark” insurance plan at 8.5 percent of income. Twenty-two million people relied on that funding, at a cost of about $35 billion annually.

With the expanded subsidies set to expire at the end of the year, reverting back to a less generous subsidy level last in place in 2021, patients around the country are facing premium increases that are so extreme, they’re either reducing health insurance coverage or dropping it altogether. Some are facing price hikes many multiples higher than they paid last year; those whose costs only doubled told the Prospect they considered themselves lucky by comparison.

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A retiree in Colorado, Jeff Rowan, described how this year’s open enrollment is driven by a sense of fear. His 2026 premium for a health plan on the state insurance exchange went from $350 a month to around $900. So he switched to a plan offered by his pension, which is $700, still a 100 percent increase. Last year, Rowan concluded that was “an outrageous amount.” Not anymore.

At one point, Rowan seriously contemplated dropping health insurance completely, he said. “But the fear of something unexpected happening and my moderate savings being wiped out is forcing me to pay the piper. It’s a completely fear-based decision.”

A small-business owner in Wisconsin, Galen Perkins, said he once made the opposite decision and lived to regret it. Years ago, he thought he could save money by skipping insurance; then he landed in the emergency room. Now, though his ACA premium is increasing by one-quarter, he’s just going to pay it and find ways to save elsewhere in his budget. He expects many people will pull back spending to the bare minimum, forgoing vacation and entertainment, and expects they will decide, “‘We’re just going to buy food, pay rent, pay health insurance, and that’s it.’ I can’t see how it doesn’t ding the economy.”

Some patients are looking for help from their elected officials, such as Rep. Seth Magaziner (D-RI), who said his constituents are describing “staggering” premium increases. One constituent, a retired marketing executive named Susan, told him that she’s currently paying about $600 a month with ACA tax credits. Next year, that will jump to $2,120, a 250 percent increase. Another constituent, Sarah, who owns a small business with her husband, said her premiums will jump from $536 a month to more than $1,000, an 89 percent increase.

“These are just a few of the stories I have heard,” Magaziner said via email. “Americans cannot afford these price increases. These spikes will break household budgets in Rhode Island and across the country.”

Staff for Sen. Michael Bennet (D-CO), meanwhile, told me they’ve fielded 3,200 messages from constituents about health care costs in this month alone.

“Working families are already struggling to get by as the costs of childcare, rent, and groceries continue to skyrocket,” Bennet said via email. “The least we could do is make things a little easier and extend the ACA premium tax credits that make their health insurance more affordable. We must fight to extend this lifeline and bring down health care costs, or countless families will be forced to go without coverage next year.”

But that’s not an option, President Trump yelled on social media Tuesday night. “THE ONLY HEALTHCARE I WILL SUPPORT OR APPROVE IS SENDING THE MONEY DIRECTLY BACK TO THE PEOPLE, WITH NOTHING GOING TO THE BIG, FAT, RICH INSURANCE COMPANIES, WHO HAVE MADE $TRILLIONS, AND RIPPED OFF AMERICA LONG ENOUGH,” he said on the website he owns.

“THE PEOPLE WILL BE ALLOWED TO NEGOTIATE AND BUY THEIR OWN, MUCH BETTER, INSURANCE. POWER TO THE PEOPLE! Congress, do not waste your time and energy on anything else. This is the only way to have great Healthcare in America!!! GET IT DONE, NOW.”

Republican lawmakers are reportedly coming up with a fix, such as giving people money directly via flexible savings accounts or health savings accounts, which they would then use to “negotiate prices” with health care companies. Fellow Prospect-er Ryan Cooper notes that this won’t work. Even Trump himself acknowledged that most people would send that money right back to insurance companies, the only entities in the economy with the leverage to negotiate with hospitals under the current system.

THE END OF ACA SUBSIDIES WITH NO PLAN IN PLACE means that people who believe they’re healthy will simply not get coverage, said Dr. Vikas Saini, president of the Lown Institute, a nonpartisan think tank focused on the health care system. The remaining population on insurance will be sicker on average, a condition that doctors and economists sometimes refer to as a worse “risk pool.” That makes it costlier for companies to insure the average policyholder. So the result of millions dropping unaffordable health insurance, as the Congressional Budget Office has forecast, will be that insurance subsequently gets more expensive.

What happens on ACA exchanges doesn’t just stay there. Because major insurance companies are the ones providing the ACA coverage, this means one way they’ll make up the loss caused by the worse risk pool is by raising premiums on their clients who get their insurance through their employer.

Taylor M., who works for a health care provider in central New York, said his employer-provided insurance is increasing by 30 percent to about $130 per pay period, an amount he said he could deal with. But the cost for those co-workers paying for their entire family is increasing from about $600 to $700 per pay period, a smaller percentage increase but a total dollar amount that’s prohibitively high.

“I would say that on some level, people may not have realized that this is what they were voting for,” he said of Trump’s re-election. “But it was what they were voting for.”

Sam, a worker in Portland, Oregon, had been stressed to find that an ACA bronze plan, the lowest-cost policy on the exchanges, would cost him about $420 a month. It would cover neither of his two generic medications nor primary care visits and also expose him to “massive deductibles.” He was instead able to get on his wife’s private insurance, but that adds an extreme new cost to the household, too, of about $500. That’s on top of the $2,600 the family now must come up with every month because they hit the benefit cliff for food stamps and free child care.

“All of a sudden, we’re really stretched thin,” he told me. “It’s just so brutal.”

Like others navigating the horror show, Sam said the cost-of-living crisis is frightening. He wonders, if Republicans are going to make health care unaffordable, will they also roll back other Democratic policies, like allowing insurance companies to deny coverage because of pre-existing conditions? Indeed, one of the options Republicans are pitching for patients without insurance is enrolling in “short-term” or “junk” insurance plans, which are not required to cover pre-existing conditions. Officials in five states have barred these products. But the Trump administration relaxed the rules governing them in August.

Sam wonders if any policy changes will harm his two-year-old son, who was born on Medicaid, which in Oregon means he can stay on it until he’s five. The situation is depressing, he said, and the logic of crushing working people is bizarre.

“It’s kind of like this war,” Sam said, “on everyone.”

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