“You’re about to be paralyzed from the waist down. You’re about to lose bowel and bladder control. You need to have spinal fusion as soon as we can get the insurance approval.”
When Dr. James Zucherman, head of orthopedic surgery at St. Mary’s Spine Center, gives you that kind of prognosis, there isn’t much more to say. That was me, in October of 2013. It was the first year that Covered California was available, and following my successful surgery, which at that time cost a mere $450,000, it was Covered California that paid for the ongoing years of physical therapy and ancillary care that have enabled me to live a full, unfettered life. As I’ve observed the dismantling of the Affordable Care Act, I’ve thought of people across the country and in my state facing health crises similar to mine, doing so at a time when access to affordable health care has been seriously compromised.
Covered California’s Executive Director Jessica Altman has been working on marketplaces “before such a thing existed,” and has been involved in every open enrollment in the state since the inaugural event in 2013. “This is a uniquely challenging open enrollment that we’re going through. Over the years, we’ve seen a lot of uncertainty and changes in political whims one way or the other, but I think this is the first time we’ve really seen the people that rely on marketplace coverage caught in the middle- facing so much uncertainty around what’s going to happen. We’re trying to navigate this as best we can- to be supportive of the nearly 2 million people that rely on Covered California today and into the future.”
The expiration of federal Enhanced Premium Tax Credits occurred on December 31st, upending the health care for thousands of people up and down the state. In a nutshell, what this means is that everyone who’s receiving Covered California tax credits will receive fewer federal tax credits. Altman notes that on average, recipients of Covered California can expect a 97% increase in their coverage cost- effectively doubling their premium cost- but that is just an overall average. Some groups will pay much, much more.
“The enhanced tax credits did two things. They made the tax credits more generous for people already receiving them, particularly for lower-income consumers whose income is just above being eligible for Medi-Cal. They also made tax credits available for first-time, middle-income consumers. Some people will receive support from state funds that will mitigate some of this impact, but not nearly enough to mitigate what was provided federally.” Middle-income consumers will bear the brunt of the expiration. “They are losing their credits altogether.”
There are a number of Covered California consumers who will fall into a “worst-case scenario” category. “The technical term is people whose income is 400% of the federal poverty level for an individual, or an income of about $65,000 a year. Absent those tax credits, these people will pay whatever the full cost of their premium is.”
People who live in rural areas, like my home in Mendocino County, can expect to pay more.
“Premiums can be much higher in some regions than others because of different factors around competition, market dynamics, and the cost of living being higher in Northern California than Southern California.”
In Mendocino County, 5,000 people were enrolled in Covered California as of June 2025, out of a population of 90,000- representing a 12.70% increase in total enrollment countywide since the Enhanced Premium Tax Credits were implemented in 2021. The net premium average per member has been $138 monthly. Altman anticipates a 172% increase in premium cost to $187 monthly, assuming the tax credits are not extended. Overall, enrollment in Northern California’s rural counties- Mendocino, Humboldt, Lake, and others is down 4% from last year. New sign-ups are down 36% from the previous year, and renewals in Northern California counties are down 1% from last year.
Older adults who are too young to qualify for Medicare are set to be hit hardest by the federal changes. Imagine a relative or neighbor living in a high-premium, rural California county. They are 60 years old, still working, but earning just a smidge above the dollar amount that would make them eligible for tax credits. “On average, this is the group that is going to experience about a $500 per month increase in what they pay. It could even be an increase of thousands of dollars or more per month in the very worst-case scenarios,” Altman notes. A 97% increase is a significant challenge for most people; this kind of increase is catastrophic, which is why Altman is focused on providing a range of possibilities to educate the public on how these changes are impacting specific populations in specific parts of the state. “Using averages can be helpful, but they can also mask the inequity of how these changes are playing out across the marketplaces.”
Who accesses Covered California? A lot of people you come in contact with on a daily basis.
“People generally come to the marketplace because we are their only option for coverage. Covered California consumers are working people who are not working in ways where they have access to an employer offering health insurance. So we’re talking about self-employed people. People in the gig economy. More than one in four farmers and agricultural workers in this country rely on market-based coverage. Caregivers, truckers, bartenders- these are the people who access Covered California. They really don’t have another option for affordable health insurance without dramatically changing how they work or what their income is.”
“I encourage people to go through their daily lives and consider, ‘How does this person get their health insurance?’ When I travel the state for open enrollment events, it’s my Uber driver who is a recipient. It’s the freelance reporter covering our events, or the small cafe owner who’s hosting an event for us. People who are used to the privilege of consistent, employer-based coverage don’t always consider the challenges of getting health care, particularly in a time of such instability.”
This year, the enrollment numbers are beginning to tell a story.
“New enrollment is down, which is separate from people who are already enrolled and deciding to renew their coverage or not. Last year, over 300,000 people enrolled. That number state-wide is down about 30% from the previous year.” As of January 3rd, more than 163,000 consumers statewide have newly enrolled in coverage- a 31% decrease from this time last year. More than 1.7 million consumers have renewed their coverage, with 29% actively selecting a plan for the 2026 plan year. However, the number of renewing consumers is expected to decrease as consumers cancel plans for next year’s coverage.
“It’s pretty clear to me from our data that these changes are having a real dampening effect on people coming to Covered California to enroll in health care.” Altman guesses there are several reasons for the decline: consumer confusion based on conflicting, unclear information in the media, people checking in but determining the costs are prohibitive, and a third group- people watching and waiting to see if a Hail-Mary rescue is coming from Congress. “I expect this trend will shape up much more in the next month or two. But the group that is losing their tax credits altogether is cancelling their coverage at double the rate compared to last year. That is a very meaningful trend.” Another trend that Altman feels confident in reporting is that more people who are renewing or newly enrolling are choosing the lower-cost Bronze coverage, particularly instead of the next-higher Silver tier. “People are choosing trade-offs from an affordability perspective.”
Altman is not optimistic about a rescue coming from Congress. “Covered California is watching this issue closely. If there are any changes or actions from Congress, we will act quickly to share updated information with enrollees about their costs for 2026 coverage. But we are in open enrollment until January 31st, and I encourage consumers to shop and enroll in coverage. What I don’t want people to do is to make assumptions based on headlines and averages. These impacts on people can be really different, depending on your particular income, where you live, and how old you are. To understand your cost for health insurance, it’s critical to really understand your circumstances.”
With more people changing their plans, Altman stresses prioritization of one’s health concerns. “Moving from a Platinum or a Gold to a Silver or Bronze plan comes with the trade-off of a higher cost-sharing. And people need to carefully think through those trade-offs, depending on their health care needs. Some people decide to move from a PPO to an HMO. Sometimes one health plan is able to negotiate better deals than another, and so switching it up can save you money- and in our data, we’re seeing this happen in real time. I truly understand, particularly for the worst-case scenario group we discussed, how acute the affordability crisis is, and for some people, insurance may not be within reach- and that’s heartbreaking.”
One misunderstanding that Altman regularly corrects is the idea that all tax credits are disappearing. “This is the way it’s been talked about. We will still have this enhancement, and the vast majority of our enrollees will still be eligible for it.”
In 2026, Bronze and minimum coverage (catastrophic) plans through Covered California will count as high-deductible health plans that allow consumers to contribute to a Health Savings Account, which is a new change to the program. In 2026, consumers may use money from their HSA to pay for direct primary care fees, which are a monthly membership fee that offers a range of primary care services. Individuals can use up to $150 a month, and families can use up to $300 a month.
It will be important for Covered California recipients to remain vigilant to upcoming changes to the program. It’s possible that the federal government will shorten the open enrollment period for plan year 2027, from November 1, 2026, to December 31, 2026.
For 2027, only certain immigrant groups will be eligible for financial help to help pay for their insurance: lawful permanent residents (green card holders), Cuban and Haitian entrants, and Compact of Free Association (COFA) migrants.
Free preventive care is available to all Covered California enrollees and covers most screenings and vaccinations. Health insurance companies in California still must provide gender-affirming care because of state rules that protect against discrimination.
Altman emphasizes her staff’s work to make the enrollment process as easy as possible, and that real-time assistance is available to those with questions. “You can do the whole process online, through our website, or you can call us. We also offer in-person enrollment assistance. We have community organizations with thousands of insurance agents who are in every community across the state. They speak dozens of languages and are there for people who are looking to navigate this process, at no cost to the consumer. We’re ready to help in any way that we can.”
For those still considering a Covered California health plan, or for those making changes to their existing coverage, the site’s “Important Changes” page highlights some of the most topical information people need to know today and moving forward. For more information, visit: www.coveredca.com/important-changes/.You may be able to save money by switching to a new health plan in a different tier or from a different health insurance company. Use the Covered California Shop and Compare Tool to compare your options. You can also call the service center at (800) 300-1506.
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