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.