Record Premiums, Record Profits

When Tom and Carol Shaw of Lewisberry, Pennsylvania opened their renewal letter from the state Marketplace late last year, their monthly premium had jumped from $1,095 to $3,505, a 221% increase. They switched to a bronze plan to bring the premium down, trading a near-zero deductible for one of $7,450 each. In February, Tom was hospitalized for a serious blood condition and hit that deductible within days. The couple has since spent close to $50,000 out of pocket. "With the wealth we have in this country," Tom Shaw told The Nation's Health, "it's ridiculous to think we cannot make healthcare more affordable for everybody who lives here."

The Shaws are not an outlier. As the roughly 160 million Americans who get coverage through work begin selecting 2027 plans, and as Marketplace open enrollment approaches, the country is moving through what economist Neale Mahoney calls three successive shocks to healthcare costs and coverage. The first landed in January 2026, when enhanced premium tax credits expired and after-subsidy Marketplace premiums rose an average of 114%. The second arrives now, as employer plan costs climb at the fastest rate in more than two decades. The third comes in January 2027, when Medicaid work-reporting requirements take effect. For people living with HIV, viral hepatitis, and substance use disorder, each shock widens the same gap: the distance between needing continuous, affordable coverage and being able to keep it.

The Employer Market: The Biggest Jump Since 2003

Workers reviewing benefits portals this fall are seeing the largest increases in a generation. Mercer projects total health benefit cost per employee will rise 8.2% in 2027, the steepest increase since 2003 and the fifth consecutive year of elevated growth. Aon puts the figure at 9.5%, pushing average cost above $19,000 per employee. PwC projects a 9.0% medical cost trend for the commercial group market, the highest it has forecast in 17 years.

Those headline numbers understate what workers will actually feel. Mercer found that 59% of employers plan benefit changes for 2027 that raise members' out-of-pocket costs, and roughly two-thirds of large employers expect to increase the employee share of premiums. More than a third of covered workers already carry single-coverage deductibles above $2,000. As employers trim coverage to hold down their own spending, including cutting GLP-1 coverage for weight management from 72% to 60% of large employers, PwC estimates the true cost growth is one to three percentage points higher than the visible trend. John Tournet of Gallagher's benefits consulting division called the familiar response of raising both premiums and deductibles every year unsustainable. For a typical worker, Mahoney estimates the 2027 increase works out to roughly $400 to $500 more.

The Marketplace: A Second Year of Double-Digit Increases, by Design

The sharpest pressure falls on the Affordable Care Act Marketplaces, and the evidence shows it is largely a product of policy, not a flaw in the program. The Urban Institute found that benchmark premiums rose 21.7% for 2026, and labeled that increase an aberration against the 2.0% average annual growth from 2020 to 2025. The ACA's structure, which ties subsidies to the second-lowest-cost silver plan, historically drove competition that kept premium growth low. What changed was not the market. It was Washington.

The enhanced premium tax credits, first passed in the 2021 American Rescue Plan Act and extended in the 2022 Inflation Reduction Act, expired on December 31, 2025 after Congress declined to renew them. KFF estimates the decision more than doubled what subsidized enrollees pay, an average increase near 114%. The average monthly payment reached $178 in 2026, 58% above the prior year and higher than the $164 people paid in 2021 before the enhanced credits existed. Insurers told regulators that roughly four to six points of their 2026 increases came from subsidy expiration alone, as healthier people dropped coverage and left a sicker, more expensive risk pool behind.

For 2027, insurers are proposing a median 15% increase in the individual market, a second straight double-digit year stacked on the roughly 20% finalized for 2026. In the small group market that covers small businesses, a KFF review of rate filings from 295 insurers across all 50 states and D.C. found a median proposed increase of 14%, with 59% of insurers seeking 10% to 20%. Individual filings range from near zero to a proposed 42.1% from UnitedHealthcare in New York. In Louisiana, proposed increases run from 10.6% to 20.2%. Insurers cite rising medical prices, specialty and GLP-1 drug spending, behavioral health utilization, and provider consolidation, alongside the morbidity shift driven by subsidy expiration.

Record Profits While Patients Pay More

The companies setting these rates are not in distress. In the second quarter of 2026, the country's largest insurers posted profits of $5.48 billion at UnitedHealth Group, $2.98 billion at CVS Health, $1.66 billion at Cigna, $1.46 billion at Elevance, $1.09 billion at Centene, and $694 million at Humana. All but Elevance posted year-over-year gains. CVS nearly tripled its profit from the same quarter a year earlier.

How these results were achieved matters more than their size. UnitedHealth's net income rose from $3.4 billion to $5.48 billion as its medical care ratio, the share of premium dollars spent on care, fell from 89.4% to 86.7%. The company credited "benefit design and pricing discipline" and exits from Marketplace and Medicare Advantage markets. Industry analysts were candid that the turnaround came from exiting unprofitable markets, trimming benefits, and raising premiums, not from any decline in underlying costs. Those exits carry a human cost: at least six insurers are leaving ACA Marketplaces for 2027, requiring roughly 650,000 people across a third of states to find new plans. Fewer premium dollars are reaching care, and fewer plans remain for the people who need them most.

Who Gets Squeezed

The coverage losses are already measurable. Marketplace effectuated enrollment fell from 21.8 million in 2025 to 19.2 million in 2026, a 12% drop and the first decline in seven years. The share of people who signed up and kept their coverage fell from 90% to 83%.

State policy choices determined who stayed covered. States using HealthCare.gov saw enrollment fall 15%, while state-based Marketplaces saw a 6% decline. New Mexico, the only state to fully replace the expired federal credits with its own funds, was the only state where enrollment grew, by 14%. The damage concentrated in high-burden states: Louisiana's effectuated enrollment fell 26%, and in several states people signed up but could not sustain the payments. The consequences reach directly into care. Federally qualified health centers report patients going weeks without medications amid 340B administrative burden and rising uncompensated care. The third shock looms in January 2027, when Medicaid work-reporting requirements take effect; CBO projects they will leave millions more uninsured by 2034, most of them people who qualify but are lost to paperwork.

For people living with HIV or hepatitis C, a coverage lapse is a treatment lapse. An interrupted antiretroviral regimen risks viral rebound and onward transmission; an interrupted course of direct-acting antivirals undercuts a cure within reach. The populations being priced out are the same ones whose continuous access determines whether we reach Ending the HIV Epidemic and HCV Elimination.

A Question for Whoever Holds the Majority

The 2027 increases are compounding a crisis that 2025 set in motion, and the near-term prospects for federal relief are thin. The current Congress is unlikely to pass anything of substance beyond a continuing resolution before the year ends, which leaves the 2027 shocks to land on families with no cushion behind them.

Voters go to the polls in roughly three weeks, and affordability sits at or near the top of what they are carrying into the booth. They are rendering judgment on a Congress that, through August 31, had enacted just 34 public laws, fewer than half the 93 passed by the same point in the last midterm cycle, according to a No Labels analysis. Whatever the outcome, the next Congress inherits a problem this one chose not to solve: enhanced premium tax credits allowed to expire, record insurer profits left unexamined, and millions of people moving toward the ranks of the uninsured while the legislative calendar stayed light.

That record raises questions worth putting directly to every member who returns in January, and to every one newly elected. Who does the system serve when its largest companies post record profits in the same quarters they raise premiums and exit the markets their members rely on? Why remove the subsidy that held coverage within reach at the moment premiums were climbing fastest? And how many more people living with HIV, hepatitis C, or substance use disorder must lose treatment before affordability becomes something Congress acts on rather than runs on?

The answers will determine whether Ending the HIV Epidemic and HCV Elimination remain reachable goals or recede into aspirations we once funded. We will be watching how the next Congress responds, and we expect the people who elected them will be too.