ACA affordability – For small-business owners and family farmers shopping on the Affordable Care Act marketplace, higher premiums and rising deductibles are forcing hard tradeoffs—delaying care, reconsidering coverage, and worrying about what happens next as work requirements and
In Pennsylvania, John Ronca runs a bike shop where his hands are the work—and lately, they’ve become part of the insurance math.
He has bought coverage through the Affordable Care Act marketplace for more than a decade. Last year, after enhanced ACA tax credits enacted under the Biden administration, the premiums for his gold plan tripled. Ronca switched down to a bronze plan with a higher deductible so his family would remain insured: himself. his wife. and a young daughter.
The move didn’t just change the paperwork. It changed the timing of care. Ronca is now putting off surgery for carpal tunnel syndrome because he can’t afford to pay for it in full. His family’s combined deductible is $14,000.
“I was really hoping to have that taken care of, but with the new deductible and the new plan, I’m pretty much pushing that off,” Ronca told me, “and owning the bike shop, my hands are my money makers.”
If Congress had to live inside the same plan choices, Ronca said, “If Congress had to have a Bronze ACA plan…it would change immediately.”
Across the country, the market’s cost pressure is showing up in similar ways—shifting families toward lower-tier plans and pushing more medical expenses onto patients right when they need care.
A new report from the nonpartisan health policy organization KFF finds that the average ACA marketplace deductible grew by about $1. 000 per person. or around $3. 000 per family. since 2025. KFF senior policy analyst Emma Wager said the shift is unsurprising: families are switching to lower-tiered plans with higher deductibles because premiums for platinum. silver and gold plans have become unattainable for many.
But the gamble is real. Wager described what families are counting on when they choose those higher-deductible plans: that they will be healthy through the year—and that their family will be too. “Families who switch are taking a chance ‘based on the fact that they’re assuming that they’re healthy. and that their family is healthy. and they won’t need that much care. ’ Wager says. ‘but they’re not all going to be correct about that for the coming year.’”.
Ronca’s family got a reminder of how quickly that assumption can unravel. When his daughter had an infection and abscess in her lip, the required procedure ended up costing his family more than $2,000.
In Iowa. Seth Watkins is living the same stress. but with different stakes—because farming doesn’t come with the safety net of predictable paychecks. Watkins seriously considered forgoing health insurance for himself this year so his wife and two children—both adults under the age of 26—could better afford coverage.
Their combined deductible this year is around $20,000.
Watkins said the shift from employer coverage to marketplace insurance has changed the day-to-day decisions his family has to make. When his wife worked a teacher’s job and they had employer-provided insurance, getting an X-ray was easy. Now. he said. there’s always a debate about whether it’s worth it cost-wise—and whether insurance will cover it.
“If Congress had to have a Bronze ACA plan,” Watkins told me, “They would not like it one bit. It would change immediately.”
The people pushing for health policy change say the affordability crunch is not just a personal hardship—it’s a systemwide risk that Congress is failing to fix.
Anthony Wright. the executive director of Families USA. said the premium spike is creating a “huge health care affordability crisis” and will keep doing so until enhanced tax credits are restored. He pointed to legislation where the outline already exists but the votes didn’t. An extension for enhanced tax credits passed the House in January. but the specific proposal died before it could be voted on in the Senate.
Wright also raised the pressure that comes from Medicaid work requirements. He said the requirements serve in part to push more people—often those who already work but still can’t afford insurance—into the marketplace.
“We’re going to have a dramatic [increase] in the people who are uninsured and also underinsured,” Wright said, “and that’s going to put strain on the health care system that we all depend on.”
For Watkins, that strain doesn’t feel theoretical. He is worried about how his local hospital will fare, and about what happens to people like family farmers when health crises arrive.
“Our politicians like to say that farmers and independent business people are the backbone of our economy,” Watkins says. “They are doing this and breaking our backs.”
Ronca, a small business owner with a different occupation but the same message, echoed the anger. “Now you’ve got a ballroom coming, we’re in a war that’s billions of dollars,” Ronca said, “but no one talks about what we need—healthcare.”
In both cases, the policy story lands in the same place: a deductible number high enough to delay care, a choice framed as coverage but experienced as cost, and families left counting on Congress to catch up—before their luck runs out again.
ACA Affordable Care Act marketplace deductibles tax credits Families USA Medicaid work requirements small business health insurance