As the clock ticked down on 2025, B. had been agonizing over her family's insurance options. She was looking for another full-time job with benefits, but so far hadn't found one. The premium prices she was seeing for 2026 Affordable Care Act plans were alarming.
She had just about decided that she and her husband would drop coverage, and only insure the kids. But it would be risky.
"My husband works with major tools all day,'' she said, "so it feels like rolling the dice."
(B. asked to be identified by her middle initial because she's worried her insurance needs might affect her ongoing job search.)
The family lives in Providence, R.I. Her husband is a self-employed woodworker, and she worked full-time as a nonprofit manager.
B. lost her job last spring. She turned to the Affordable Care Act marketplace. The family's "gold" plan cost them nearly $2,000 a month in premiums.
It was a lot, and they dug into retirement savings to pay for it, while B. kept looking for a new position.
But then Congress failed to extend the enhanced subsidies for those plans, despite ongoing political battles over the issue and a lengthy government shutdown.
With subsidies expiring, B.'s family plan will cost even more — almost $3,000 a month in the new year.
"I don't have an additional $900 lying around in my family budget to pay for this," she said.
Millions of middle-class Americans who have ACA health plans are facing soaring premiums in 2026 — and tough coverage choices after the new rates kick in Jan. 1. And it often falls to women to figure out a family's insurance puzzle.
Women generally use more health care than men, in part because of their need for reproductive services, according to Elizabeth Tobin-Tyler, a professor at Brown University School of Public Health.
Women also tend to be the medical decision makers for the family, she said, especially for the children.
"There's a disproportionate role that women play in families around, what we think of as the mental load,'' said Tobin-Tyler, and that includes "making decisions around health insurance.''
Brooklyn-based performer Cynthia Freeman, 61, has been trying to figure out how to keep the ACA health plan that she and her husband depend on.
"If we didn't have health issues, I'd just go back to where I was in my 40s and not have health insurance,'' she said, "but we're not in that position now.''
Freeman and her husband, Brad Lawrence, are freelancers who work in storytelling and podcasting.
In October, Lawrence, 52, got very sick, very fast.
"I knew I was in trouble," he said. "I went into the emergency room….and I said, 'Hi, I've gained 25 pounds in 5 days and I'm having trouble breathing and my chest hurts.' And they stopped blinking."
Doctors diagnosed him with kidney disease, and he was hospitalized for four days.
Now Lawrence has to take medication with an average cost of $760 a month without insurance.
In January, the cost of their current "silver" plan will rise nearly 75%, to $801 a month.
The marketplace price assumes the couple brings in a combined income of about $60,000 in 2026 — 40% less than they earned last year, because right now Lawrence isn't working.
"We can't survive on [$60,000],'' Freeman said, "but at least we can go into the year saying that, so we [are] able to get some form of a subsidy."
Lawrence does plan to return to work. But if their household income tops $100,000 in 2026, like it did in 2024, they would no longer qualify for any type of insurance subsidy – and their premiums would top $2,000 a month. That's almost as much as they pay in rent.
To bring in extra cash, Freeman has picked up a part-time bartending gig.
Before the holidays, Congress considered a few forms of relief for the premium hikes, but nothing has materialized, and significant deadlines have already passed.
Freeman is now thinking about applying for a full-time bartending job at a hotel chain, which comes with health benefits.
"It's one thing to have it as a little side gig,'' she said, "it's another thing to be looking at going into my '60s and the best choice for me is getting a corporate job as a bartender at a hotel."
For Nicole Benisch, the prospect of soaring insurance premiums has put a pause on her plans to get married.
Benisch, 45, owns a holistic wellness business in Providence, R.I. For coverage, she pays $108 a month for a zero-deductible "silver" plan on Rhode Island's marketplace exchange.
But the monthly cost in 2026 will more than double, to $220 per month.
She and her fiancé had planned to marry on Dec.19, her late mother's birthday. "And then,'' she said, "we realized how drastically that was going to change the cost of my premium."
As a married couple, their combined income would exceed 400% of the federal poverty level, and make Benisch ineligible for any financial help with coverage. To maintain her current plan, her monthly premiums would triple, costing her more than $700 a month.
Benisch did look at a less expensive "bronze" plan, but it wouldn't cover vocal therapy, which she needs to treat muscle tension dysphoria, a condition that can make her voice strain or give out.
If they get married, there's another option: switch to her fiancé's health plan in Massachusetts. That would mean losing all of her Rhode Island doctors, who would be out-of-network.
"We have some tough decisions to make,'' she said, "and none of the options are really great for us.''
For B., the looming deadline spurred her to keep researching options and weighing the pros and cons.
As Christmas approached, she still had not landed a new full-time job with benefits. She had already pulled $12,000 out of retirement funds to pay the 2025 rates.
Until B. finds a new job, the family's projected income for 2026 will be less than 250% of the federal poverty level. That means the children qualify for free coverage through Medicaid.
For herself and her husband, she'll buy a plan on the ACA marketplace, paying premiums of $1,200 a month.
"The bottom line is none of this is affordable,'' she said, "so we're gonna be dipping into savings to pay for this.''
This story comes from NPR's health reporting partnership with KFF Health News.
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