CINCINNATI — For four years, Kimberly Dudley has worked on the front line of the Affordable Care Act as a navigator, helping Ohioans solve the puzzle of buying private insurance on the federal HealthCare.gov marketplace.

But the job is harder now, the answers scarcer. In one of its first acts, the second Trump administration cut annual funding for navigators by 90%, from $100 million to $10 million, arguing the program was wasteful. Under the ACA, better known as Obamacare, navigators help educate and enroll people — especially those living in hard-to-reach communities. They were paid through a user fee on monthly premiums.

In January 2025, 50 navigators served Ohio’s 88 counties, toting their laptops to meet Ohioans at rural libraries and suburban food courts to help them search for a health care plan on the marketplace. But by the Nov. 1 start of open enrollment, the busiest time of year, only five navigators remained. Dudley, of Cincinnati, is one of them.

Married with a child, she was hired in 2022 at Cincinnati’s Freestore Foodbank and found “such a joy from helping people, although it’s been hard this year.” The hotline, for example, is in Dudley’s hands now. The other navigators who worked calls were laid off.

The administration did not respond to requests last week to discuss the navigator program cut. But in announcing the cuts last year, an administration statement said: “Navigators are not enrolling nearly enough people to justify the substantial amount of federal dollars previously spent on the program. This reduction will ensure funding is focused on meeting the statutory goals of the program more efficiently and effectively.”

Dudley’s task got even tougher at the end of last year, when the Trump administration and Congress allowed certain pandemic-era subsidies to expire, and policy premiums rose sharply, often to more than many Ohioans can pay.

She hears the stories every day on her own phone, which doubles as Ohio’s ACA hotline. People call when they are ruled ineligible for Medicaid, usually because their incomes are too high. In early March, Dudley heard from Tonya Horn, 59, of Cleveland Heights, who needed help.

All her working life, said Horn, she felt lucky to have employer-paid health benefits up to her most recent job, working remotely for Empower, a Colorado financial services company, as a talent acquisition diversity program manager. But last year, her job at Empower felt less secure. Her pink slip came in January.

Helping Horn, Dudley spotted a plan on HealthCare.gov that with an income-based subsidy would cost $450 a month with no deductible. But then Dudley discovered that Horn’s doctor does not accept that insurance plan.

“I don’t know if this works for you,” Dudley said, “but getting insurance could involve switching doctors.”

Horn sighed. “Can we keep looking?”

Drop in enrollment

This year, Ohio’s enrollment in the HealthCare.gov marketplace fell by 20%, the second-largest decline among the 50 states. The overall national enrollment slid 5%.

Experts in Ohio said a few factors depressed enrollment. Some people aged into Medicare. Others found jobs with health benefits. But one certain force was the Dec. 31 expiration of the pandemic-era subsidies on most marketplace plans.

The ACA does provide premium subsidies based on income, but the federal government began offering additional help in 2021 as temporary pandemic relief. The “enhanced” subsidies cut many people’s monthly premiums by hundreds of dollars.

They also helped boost the number of people buying health coverage from the insurance marketplaces, from 11.4 million people in 2020 to 24.3 million last year.

Americans who had the enhanced subsidies got warnings from their insurers about the Dec. 31 expiration. As of March 26, the number of Americans with marketplace coverage dropped by about 1.2 million compared with 2025, according to the Centers for Medicare & Medicaid Services.

Last week, a spokesperson for U.S. Sen. Jon Husted, an Ohio Republican, said that Husted proposed to extend the subsidies two more years, with new restrictions to prevent fraud in marketplace plans. Democrats rejected the idea, said Joshua Eck, Husted’s deputy chief of staff. “But had they supported the bill, or been willing to discuss it, it’s likely this problem would have been solved in December.”

In Ohio, the Columbus nonprofit research group Health Policy Institute of Ohio found that of the more than 580,000 Ohioans with 2025 HealthCare.gov plans, nearly 90% used the temporary subsidies.

California and at least nine other states that run their own health insurance marketplaces have used state money to help residents absorb the expiration price shock, though only New Mexico is completely filling the gap. Ohio could not dip into its budget that way because it uses the federal marketplace.

In January, the Health Policy Institute of Ohio estimated that 2026 premiums for Ohio marketplace plans would surge by 114% on average. Said institute analyst Brian O’Rourke: “It’s reasonable to expect that (the enrollment drop is) because of the expiration of the subsidies.”

On the statewide ACA hotline call with Horn, Kimberly Dudley said her own mother got a notice from her insurance company that her $40-a-month premium would increase to $400. “I was able to help her figure out a plan, but her premium still went up some,” Dudley said. “We’re going to find a way forward for you.”

“I hope so,” Horn said.

Ohio expands the ACA

Ohio’s industrial base collapsed in the 1990s, and hundreds of thousands of workers lost employer-paid coverage. Young people left Ohio for work, and the insurance pool shrank as it rapidly aged. Numerous studies found Ohio’s health declining, in no small part because nearly 1.5 million Ohioans, more than 10% of the population, had zero health insurance.

The ACA also allowed states to expand Medicaid to adults with incomes up to 138% of the poverty level, although some Republican-led states have refused the expansion. In Ohio, GOP Gov. John Kasich pushed the Republican-led state legislature to approve the expansion in 2013; 40 states and the District of Columbia have expanded their programs. Ohio’s participation in the federal marketplace grew until 2025, when enrollment hit a record high.

The speed of the retreat in Ohio of the ACA brought swift consequences. The Columbus nonprofit group UHCAN Ohio “has been helping people since the law’s inception,” said Executive Director Charlotte Rudolph. Then last fall, “If we saw five people, maybe one enrolled. They’re making that tough decision to say, ‘I hope I don’t get sick.’”

“We are now going through our archives, asking ourselves, how did we help people back in the day when they didn’t have coverage?”

Further complicating Ohio’s health care horizon are Trump administration cuts to Medicaid. More than 3 million Ohioans use the health program for low-income residents. But under the broad tax and spending measure President Donald Trump signed last summer, as many as 1 in 10 of those Ohioans could be found ineligible through new work requirements and other hurdles.

Horn, on the hotline phone call, said her weekly $624 unemployment payments had put her over the Medicaid threshold. Dudley nodded as she tapped on her keyboard. “I hear that a lot,” she said.

What the future holds

While the immediate problems are stressing the system, experts say they are anxious for what is to come in Ohio’s health care.

Uninsured people often use emergency departments for primary care, straining hospitals still under pandemic duress and understaffed. Many Ohioans on Medicaid live in its rural spaces, where the safety net has long been fraying. The trade group the Ohio Hospital Association told the state legislature last year that more than 70% of the state’s rural hospitals have been running in the red for years.

“My fears,” said Grace Wagner of the Ohio Association of Foodbanks, “are that as these changes continue to come, decision-makers aren’t aware or prepared to respond.”

Dudley and Horn spent another 30 minutes on the ACA hotline, but none of the HealthCare.gov options clicked. Finally, Horn said she would call back.

“Sure, it’s a lot to think about,” Dudley said, and ended the call. Then she sat looking at her laptop screen full of HealthCare.gov. She doesn’t like to leave a puzzle unsolved for someone who came to her for help.

“I love what I do. Being able to do this work is fantastic, even in the midst of all this stuff happening,” she said. “But there are times when I feel a little overwhelmed.”

Ten Democratic-leaning states are using their own money to help people buy Obamacare health plans, at least partially replacing the federal tax credits that expired at the end of last year.

The state assistance, some of it offered through programs that existed before the federal subsidies expired, is helping hundreds of thousands of people lower their monthly premium payments, which otherwise would have surged to double or even triple what they were before the expiration of the federal aid. The savings can total hundreds of dollars per month.

But only New Mexico is completely filling the gap left by the expiration of the federal help by offering it to people of all incomes; for most Americans buying Obamacare plans, the end of the federal aid means much higher prices. And New Mexico and the other states that are trying to cushion the blow for their residents will face increasing budget pressures as health care costs continue their inexorable rise.

In addition to the expiration of the federal subsidies, the cost of Obamacare coverage has increased because of other factors, including labor shortages and the rising cost of prescription drugs, driven in part by the growing demand for GLP-1 drugs such as Ozempic and Wegovy.

The enhanced federal subsidies were made available by the American Rescue Plan Act in 2021 and later extended through the end of 2025 by the Inflation Reduction Act. Designed as a temporary pandemic-era measure, they helped boost the number of people buying health coverage from the insurance marketplaces created under the Affordable Care Act — Obamacare’s formal name — from 11.4 million people in 2020 to 24.3 million last year.

The enhanced subsidies were available to everyone, regardless of income. Additional federal aid provided to some of the lowest-income households entirely eliminated premium payments for some people.

Congressional leaders let the subsidies expire on Dec. 31. As of the end of last month, the number of people enrolled in marketplace coverage was down by about 1.2 million compared with last year, according to federal data.

Last year, the Congressional Budget Office estimated that the expiration of the federal subsidies would increase the number of people without insurance by 4.2 million by 2034.

Under the Affordable Care Act, each state can either use the federal government’s online insurance marketplace, HealthCare.gov, or operate its own state-run exchange. Only the 21 states plus the District of Columbia with state-run marketplaces can offer state-funded tax credits or subsidies, and at least 10 of them (California, Colorado, Connecticut, Maryland, Massachusetts, New Jersey, New Mexico, New York, Vermont and Washington) are doing so.

Matt McGough, a policy analyst at health care research group KFF, said many of the people who buy Obamacare plans “have fallen between the cracks of the health care system.”

“They might not work a job or work enough hours at a job to be eligible for health benefits. They are too young for Medicare. They make too much to be eligible for Medicaid, and they really have no other option but to go to the marketplace,” McGough said.

He warned that relatively healthy people are the ones most likely to forgo marketplace coverage rather than pay more for it. That will leave the exchanges with the people who have the greatest health needs, raising costs and premiums for everyone. To avoid that scenario, he said, states “want to be able to keep as many people in the marketplace as possible.”

A big commitment in New Mexico

In New Mexico, Democratic Gov. Michelle Lujan Grisham and state lawmakers earlier this year tapped the state’s 5-year-old Health Care Affordability Fund for an additional $17.3 million so they could entirely replace the expired federal subsidies through June 30 for all enrollees, regardless of income.

The vast majority of the 82,400 New Mexicans who buy coverage from the state marketplace are eligible for state help. Perhaps as a result, New Mexico is one of only a handful of states where the number of people buying Obamacare plans has increased this year: Enrollment is up 18% in New Mexico, while there have been single-digit increases in the District of Columbia, Maryland and Texas.

“We feel really great about having come together to really focus on these affordability challenges for New Mexicans, and really proud of the gains that we’ve made in coverage while we’re seeing losses elsewhere,” said Kari Armijo, cabinet secretary for the New Mexico Health Care Authority. She noted that a handful of Republican state lawmakers have joined Democrats in supporting the aid.

The money in New Mexico’s Health Care Affordability Fund comes from a 3.75% surtax levied on insurance companies. When the fund was created, the surtax was expected to generate about $165 million in new revenue annually.

Currently, the state uses nearly half of the revenue from the surtax to fund other parts of its budget. But the New Mexico House earlier this month approved a bill that would gradually increase the portion of the surtax allocated to the Health Care Affordability Fund, from the current 55% to 100% in 2028.

Legislative financial analysts recently questioned the long-term sustainability of that approach. Armijo acknowledged that continuing to replace the expired federal subsidies “will deplete the fund over time.”

“It is a pretty substantial amount of money, and it is going to strain the programs that we can provide with that funding,” Armijo said.

Paul Gessing, president of the Rio Grande Foundation, a conservative-leaning think tank in New Mexico, said the state is “flush with oil and gas money” now, enabling it to “spend money in ways that don’t make a great deal of sense for the population as a whole and instead benefits a small sliver of relatively well-off New Mexicans.”

Gessing said the state should focus on reducing health care spending by recruiting and retaining more doctors and nurses to lessen its shortage of providers and by overhauling medical malpractice laws.

“I don’t think the state should make it a practice to use state funds to fill in the gap when federal funding is shifted or eliminated,” Gessing said.

Other states

In California, where 1.9 million people were enrolled on the state’s exchange in 2025, enrollment is already down by 32% from last year, according to state figures.

The state has opted this year to spend $190 million to fully replace the lost federal subsidies for people earning up to 150% of the federal poverty level ($23,940 for an individual), and partially replace them for people making between 150% and 165% of the federal poverty level — just above eligibility for Medicaid in the state. About 390,000 enrollees are receiving the state-based subsidies this year.

Like New Mexico, California in 2021 created a Health Care Affordability Reserve Fund, funded through general revenue and penalties some people have to pay when they file their taxes.

The state budget Democratic Gov. Gavin Newsom proposed last month envisions a “modest projected deficit” of $2.9 billion for fiscal year 2026-2027, but that could grow to $22 billion the next year. California has a total annual budget of about $350 billion.

“Any amount of money that you can put into affordability is meaningful,” said Jessica Altman, executive director of California’s marketplace. “Thinking about those trade-offs is a challenging conversation, but an important one at the state level.”

In Colorado, the state is offering financial help through a new program called the Colorado Premium Assistance program. It came together during an August 2025 special session, when Colorado lawmakers approved up to $110 million this year to partially replace the federal subsidies. Help will be available to anyone making between 133% and 400% of the federal poverty level, or between $43,890 and $132,000 for a family of four.

“It is clear that this is a value for Coloradans. And having a state based marketplace like we do in Colorado, it really allows us to develop state-specific solutions and have our policies and changes driven by the needs of the people who live here,” said Nina Schwartz, chief policy and external affairs officer for Colorado’s marketplace.

Schwartz emphasized, however, that the state help won’t entirely replace the expired federal aid, and that as a result, the number of people buying coverage on the exchange is declining. Cancellations are up 83% compared with last year.

“We’re seeing an increase in the number of cancellations, with the number of people nearly doubling who canceled their plans during open enrollment compared to last year,” she said.

Other states also are opting for limited assistance. Connecticut, for example, is offering aid to households with incomes up to 200% of the federal poverty level, and the state announced it would spend $115 million in 2026 to partially offset the expiration of the federal subsidies.

Massachusetts has set aside $250 million to enhance its existing state subsidy program, helping to keep around 270,000 enrollees with incomes below 400% of the federal poverty level enrolled with stable premiums. As of early January, around 25,000 people in Massachusetts had already canceled their marketplace plans.

Maryland has a new premium assistance program that fully replaces the federal aid for enrollees earning below 200% of the federal poverty level and partly replaces it for those earning between 200% and 400% of the federal poverty level. Since last year, New York has offered help to marketplace enrollees with incomes up to 400% of the federal poverty level. And since 2023, Washington has offered state subsidies to anyone earning below 250% of the federal poverty level.

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org. 

Reading Time: 6 minutes

Click here to read highlights from the story

• Free clinics like Bread of Healing in Milwaukee and Open Arms Free Clinic in Walworth County serve as a final safety net for community members who can’t afford health care.

• They are bracing for higher demand as more residents are expected to forgo insurance as a crucial tax credit is set to expire and premiums spike.

• Clinic staff say they may need more resources to meet demand. 

• The U.S. Senate on Thursday rejected dueling plans related to helping people pay for plans on the federal marketplace.

Editor’s note: This story has been updated to note the U.S. Senate’s rejection on Thursday of legislation to address the expected rise in health care premiums.

Cars filled the small parking lot outside of Milwaukee’s Cross Lutheran Church on a recent Monday afternoon. The church’s pews sat empty, but downstairs visitors waited around folding tables. Not to hear a sermon, but to see a volunteer physician. 

Staff and volunteers walked patients past a row of dividers used to separate the “waiting room” from the folding tables where doctors and counselors filled out paperwork. 

In front of the free health clinic’s four exam rooms, two phones rang. 

“This is the Bread of Healing Clinic. Can you hold for a moment?” asked Diane Hill Horton, the free health clinic’s assistant.

Across from Hill Horton, another staff member scheduled an appointment in Spanish. 

On a typical Monday, the clinic sees up to 30 patients. Bread of Healing treated 2,400 patients in 2024 across three clinics it runs in Milwaukee. Patients typically lack any health coverage and aren’t asked to pay for their visits.

“We don’t turn anyone away,” Hill Horton said.

But without action from lawmakers in Washington, clinic staff worry that it will become harder to answer every call.

Free clinics like Bread of Healing serve as a final safety net for community members who can’t afford health care. They are bracing for higher demand as more residents are expected to forgo insurance as a crucial tax credit is set to expire and premiums spike.

Affordable Care Act premiums in Wisconsin will increase on average by 17.4% next year, a previous Wisconsin Watch analysis showed, with wide variation depending on age, income, family status and geography. Meanwhile, experts estimate more than 270,000 Wisconsinites rely on the enhanced premium tax credit to make insurance more affordable. It will expire at the end of the month without intervention. 

People without insurance are less likely to get preventative care. Bread of Healing focuses on treating chronic conditions to prevent people from overwhelming emergency rooms, said Executive Director Erica Wright.

“If we don’t try our best to move with that demand, we’re not going to be able to see as many people, and there’s going to be a lot of folks falling through the cracks,” she said.

Wright oversees all three Bread of Healing locations. While the clinics have some room to take on more patients right now, she wants to significantly increase their capacity over the next year — adding money and volunteers to serve a possible “monsoon” of demand.

“We’re never going to be able to serve everybody, we know that,” Wright said. “But I don’t want it to be where our phones are ringing off the hook and we just can’t meet at least a good chunk of the demand.”

Higher premiums and shrinking options

Ashley Bratz paid about $545 a month for a low-deductible marketplace plan this year. That same plan cost over $700 when she went to sign up for 2026.

Even with her job at Open Arms Free Clinic in Walworth County covering a portion of her health care costs, the only option in Bratz’s price range had deductibles higher than what she expects to spend.

 “It’s supposed to be reasonable, and this is not reasonable,” Bratz said.

Bratz, who works as the nurse clinic coordinator, said she did not receive enhanced marketplace subsidies this year. Those who did will face a particular shock as the tax credit expires — while also confronting rising prices and shrinking options.

The income-based tax credits have lowered some marketplace enrollees’ monthly premium payments since they became available in 2014.

In 2021, the federal government expanded those subsidies, further bringing costs down for lower-income enrollees and extending smaller subsidies to people making over four times the  federal poverty level — $62,600 a year for one person in 2025.

Without an extension, monthly premiums are expected to more than double on average nationally for subsidized enrollees, according to KFF, an independent source for health policy research.

A quarter of enrollees surveyed by KFF said they were “very likely” to go without insurance if their premiums doubled.

The U.S. Senate on Thursday rejected a Democratic plan to extend marketplace subsidies. Republicans, who have long criticized the Affordable Care Act (ACA), have instead called for a broader overhaul. The Senate also rejected a Republican plan that would have expanded access to high-deductible insurance plans and deposit $1,000 to $1,500 in enrollees’ health savings accounts — without renewing enhanced subsidies.

Sara Nichols, Open Arms Clinic executive director, is forging ahead regardless. When Bratz told her about her shrinking affordable coverage options, Nichols started working with an insurance broker to find a new plan for the clinic’s small team of paid staff.

“We cannot have health care workers not have health insurance,” Nichols said.

The move left Bratz relieved. Now she’s preparing to help more clients who can’t afford coverage or just need help navigating the complicated system.

They face challenges beyond lost subsidies and premium hikes. President Donald Trump’s “big” bill-turned law included additional changes to Medicaid funding and the ACA that are expected to increase the number of people without insurance by 10 million over the next decade, according to the Congressional Budget Office.

“We always take what is thrown at us and we figure out how to handle it,” Bratz said. “Do I think we could also use more help? Yes.”

Resources needed to meet demand

Open Arms Free Clinic is already seeing higher demand, Nichols said. 

It operates a dental clinic five days a week, and she’s considering whether further demand would require opening its medical clinic for an additional day.

That would take more volunteers and money. 

While the Legislature sent state dollars to free clinics in its latest budget, private grants and donations have been harder to secure this year, Nichols said. She expects the clinic will have to get even leaner next year.

But she won’t start turning patients away.

The clinic provides dental, medical and behavioral health to low-income people who live and work in Walworth County. Its 250 volunteers help with things like translating, nursing, greeting patients and connecting people to the clinic. They also provide vision and pharmacy services.

“I know that we have enough smart people and kind people that we’re going to come up with a solution to anything that comes up,” Nichols said.

This is far from the first time Wisconsin’s free clinics have faced big changes, said Dennis Skrajewski, the executive director of the Wisconsin Association of Free and Charitable Clinics. 

Free clinics adapted to the COVID-19 pandemic, operating with fewer volunteers and switching to telehealth services and opening vaccine programs, Skrajewski said. Then clinics prepped for increased demand in 2023 after Medicaid unwinding.

“We’re used to waking up and the world changed yesterday, so we’ll adjust,” Skrajewski said.

Wisconsin’s free and charitable clinic association is collaborating with other safety net health providers as part of the Wisconsin Owns Wellbeing initiative, which will host statewide planning meetings to strengthen the state’s safety net services. 

Clinic co-founder: ‘I just wish it weren’t needed’ 

Rick Cesar started working as a parish nurse at Cross Lutheran Church in the 1990s. He took people’s blood pressure at a weekly food pantry and ran an HIV testing site and needle exchange out of the church’s basement.

He helped co-found the Bread of Healing Clinic in 2000, a decade before the ACA passed. 

“There were so many people that had no coverage,” Cesar said.

Demand for free services persisted even after more people enrolled in marketplace plans. The clinic expanded to two other locations and hired paid staff. Cesar retired from nursing in 2019 but still regularly volunteers. He feels proud watching the clinic grow.

“I just wish it weren’t needed,” he said.

The clinic is adaptable, Cesar said, whether it’s responding to a pandemic with vaccine drives or helping clients navigate ACA changes.

“We’re going to be here and do as much as we can,” Cesar said. “But those resources, you never know how long they are going to last when the demand is so great.”

‘We don’t turn anyone away’: Wisconsin’s free clinics fill gaps as thousands expected to go uninsured is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.