More than three centuries ago, shipowners, merchants, and underwriters gathered at Edward Lloyd’s coffee house in London. The insurance market that grew from those gatherings helped spread the financial risk of voyages that could end in shipwreck or lost cargo. In exchange for a premium, underwriters accepted an agreed share of the potential loss.
The principle remains straightforward: pay for protection against a loss you could not afford to bear alone. What happens when people can no longer afford the protection — or the protection they can afford leaves them with bills they still cannot pay?
That question hangs over the ACA’s latest open enrollment period. ACA Marketplace benchmark silver premiums will rise an average of 13% in 2027, following a 26% increase for 2026. Together, those increases put benchmark premiums roughly 42% above their 2025 level, before subsidies. Patients must decide how much protection they can afford. Hospitals should be considering how much financial risk those decisions will leave them carrying.
Health coverage is taking a bigger bite out of household budgets
The ACA expanded access to insurance for millions of Americans. Its promise depends on people being able to maintain coverage and afford care when they need it.
When Marketplace coverage began in 2014, the national average benchmark silver premium for a 40-year-old was $273 a month. For 2027, that figure reaches $704, an increase of 158%. That is $8,448 a year before deductibles, copays, and coinsurance.
Household income has grown, too, but coverage has consumed more ground. From 2014 to 2025, median household income rose from $53,657 to $87,460, about 63%. Over those same years, the benchmark premium increased 82%. These are dollar comparisons without an inflation adjustment; 2027 household income data are not yet available.
Premium tax credits cushion the expense for eligible households. People earning more than 400% of the federal poverty level, however, lost eligibility for federal premium assistance when enhanced credits expired. They face the full price of coverage.
The protection available after paying the premium has changed as well. In 2014, the annual out-of-pocket ceiling was $6,350 for an individual and $12,700 for a family. The 2027 ceilings reach $12,000 and $24,000, an increase of 89%. Plans can set lower limits, but premiums remain outside them.
Patients gamble on what healthcare costs they can afford
Faced with those costs, a person who feels healthy may decide to save the premium and take their chances. Others preserve coverage by choosing a lower monthly payment and accepting greater exposure when they need care.
We cannot assume everyone leaving the exchanges has made that calculation. But the evidence shows cost driving decisions. In a KFF follow-up survey, 9% of 2025 Marketplace enrollees reported being uninsured in early 2026. Among respondents who became uninsured or switched Marketplace plans, 80% cited expense as a reason for the change.
Keeping coverage can involve a substantial gamble, too. One CMS standardized expanded bronze design for 2027 has a $7,500 individual deductible and 50% coinsurance after the deductible for inpatient hospital services, up to a $12,000 out-of-pocket maximum. Certain services have copays before the deductible, but a hospitalization can still leave a patient with a bill far beyond their savings.
For that patient, insurance may protect against a catastrophic total bill while leaving an unaffordable personal one. Financial fear can determine whether treatment happens at all. Patients postpone an appointment, delay a test, or hope symptoms resolve because they cannot see a financially manageable way forward.
Hospitals share the risk of bills underinsured patients cannot pay
Patients’ financial gambles become providers’ financial exposure. When an uninsured patient needs expensive treatment, the hospital may have little prospect of collecting the full bill. A patient with insurance and an unaffordable deductible can present a similar collection problem.
The hospital has staff to pay, supplies to purchase, and capacity to maintain regardless of how much that patient can contribute. The cost of care remains even when payment does not materialize.
That makes benefit design an access issue and a financial planning issue for providers. An insurance card confirms coverage. It does not establish that the patient can afford recommended treatment or meet the resulting obligation.
Health systems need to examine that exposure at the product and plan level. A patient can remain in the commercial category while moving to a plan with different reimbursement and substantially higher patient responsibility. Financial forecasts should account for what patients can realistically pay, alongside what contracts permit hospitals to collect.
Providers also need to identify financial barriers before patients abandon care. That means understandable estimates, accessible financial assistance, and a direct connection to someone who can help with coverage and payment questions. Those efforts cannot make an unaffordable plan affordable, but they can help patients find available support before treatment is interrupted.
Insurance developed to spread losses people could not bear alone. As coverage becomes harder to afford and use, more of that exposure lands with patients and providers. Apparently, “shared risk” means more risk and financial burden to patients and hospitals, not the insurer who you pay to hold the risk.
