2026年6月15日 美国东部时间5:00 / KFF健康新闻
北卡罗来纳州斯嘉鲁格——多年来，罗斯·托比亚森和丽贝卡·托比亚森夫妇的医疗成本持续上涨，自2014年《平价医疗法案》（奥巴马医改）推出以来，他们一直依靠该法案获得联邦补贴的医疗保险。年复一年，这对北卡罗来纳州西部的夫妇一直保留着医保，认为这份安心值得付出的代价。
但去年12月，情况变了。当丽贝卡发现他们的月保费将从130美元跃升至550美元以上时，托比亚森夫妇决定取消医保。
“这毫无道理，”她说，“已经不值得了。”
丽贝卡和罗斯·托比亚森去年因费用过高取消了《平价医疗法案》医保。安德鲁·琼斯/KFF健康新闻 摄
这对夫妇拥有一家小型汽车修理店，也是唯一的雇员，店铺就位于北卡罗来纳州山区的阿巴拉契亚州立大学西侧。丽贝卡担心丈夫的工作安全：作为机械师，他的工作充满危险。有一次，弹簧像子弹一样将金属球头弹进了他们的车库墙壁。还有一次重物压伤了罗斯的拇指。2020年，罗斯的眼睛反复进入金属碎片并引发角膜感染，导致一只眼睛几乎完全失明。
托比亚森夫妇是在国会于2025年底终止用于支付医保保费的强化税收抵免后，取消《平价医疗法案》医保的美国人之一。托比亚森夫妇曾从这些税收抵免中获益——就像数百万其他参保者一样，随着2026年的推进，他们将因无法承担更高的费用而放弃或被取消医保。
这些扩大的补贴是拜登政府在新冠疫情期间通过《美国救援计划法案》设立的，它降低了许多家庭的月保费，并推动了一波新参保热潮，使得《平价医疗法案》的参保人数翻番至约2400万。
美国医疗保险和医疗补助服务中心预计很快将公布不再参保《平价医疗法案》的完整数据，但KFF引用瓦克利咨询集团的研究进行的早期分析显示，参保人数可能从2025年底的2200多万降至2026年的1650万。
根据参保数据，北卡罗来纳州2026年的个人《平价医疗法案》参保人数较前一年下降了22%，降幅超过其他任何州，减少了超过21.3万人。虽然托比亚森夫妇的两个十几岁的女儿仍在医疗补助计划中，但丽贝卡表示，新的保费价格表明联邦政府并不关心像他们这样的家庭。
“我们早就知道你们不在乎我们，”她说，“但现在你们表现得再明显不过了。”
这对夫妇的医保也未能覆盖他们所有的医疗需求。五年前，罗斯的眼痛加剧，丽贝卡坚持让他去看专科医生，医生告知他们，通过角膜置换手术修复眼睛的费用高达3万美元，且罗斯需要休假六个月。
罗斯选择了更便宜的治疗方案，通过破坏眼部神经来缓解疼痛。
这对夫妇知道，没有医保意味着他们在承担风险。如果发生什么意外，他们可能会面临巨额医疗账单。
47岁的罗斯表示，一只眼睛失明并未对他的工作造成重大影响。他长时间工作，有时甚至加班到深夜以满足订单需求。
“我尽量不去想太多，”他说，“我只是工作。”
罗斯·托比亚森和妻子共同经营的汽车修理店就建在北卡罗来纳州西部自家住宅旁的土地上。安德鲁·琼斯/KFF健康新闻 摄
凯蒂·亚历山大是北卡罗来纳州西部非营利组织皮斯加法律服务中心的志愿者负责人，该机构帮助低收入人群获得医保。自奥巴马医改推出以来，亚历山大一直在帮助北卡罗来纳州和田纳西州的居民申请《平价医疗法案》医保市场计划。她表示，自己从未见过今年这样的情况。
亚历山大表示，在开放注册期间，她的团队对接的约700名客户中，有近100人决定今年放弃医保，还有许多人选择了保费更低、保障范围也更窄的《平价医疗法案》计划。
亚历山大说，放弃医保的人包括优步和来福车司机，他们正尝试创业，还有艺术家以及因慢性病只能做兼职的人。有些人无法通过雇主获得医保，还有些人的收入过高，不符合医疗补助计划的申领条件。
“即使是没有慢性病的人，”亚历山大说，“脑海里也会一直萦绕着一个挥之不去的念头：‘别受伤，别生病。因为你根本负担不起医疗费用。’”
根据KFF分析的数据，自2022年起，《平价医疗法案》的保费和免赔额逐年稳步上涨，在2026年医保计划的注册期间更是出现了飙升。托比亚森夫妇见证了自2014年医保计划推出以来，保费的每一次涨跌。丽贝卡·托比亚森说，他们从一开始就加入了该计划，当时每月只需支付约30美元。
“你真的会觉得自己享受到了实惠，”她说。
但多年来，随着医保市场的费用越来越高，这对夫妇做出了妥协：一度从历来最受欢迎的白银计划转为青铜计划。该计划基本只能满足这对夫妇的基本医疗需求。
十多年来，随着免赔额和保费不断上涨，丽贝卡担心总有一天，他们连最便宜的医保计划都负担不起。
“无论怎么算，医保计划都太贵了，”科罗拉多大学安舒茨医学院的医疗政策研究员里沙·吉德瓦尼说，“问题只是谁来承担这笔无法负担的费用。”
吉德瓦尼和健康经济学家谢丽尔·达姆伯格在今年早些时候发表的一项研究中发现，对于许多人来说，即使是最便宜的《平价医疗法案》选项——青铜计划，如果没有补贴，对普通参保者来说也难以负担。
吉德瓦尼的研究显示，如果没有补贴，许多参保家庭的收入不足以支付保费或免赔额。
吉德瓦尼表示，放弃医保的人还会改变所谓的“风险池”，即一群人共同分担财务风险的机制。
如果更健康的人退出风险池，那么为患病参保者提供补贴的人就会减少，吉德瓦尼说。这意味着未来患病参保者的保费将再次上涨，她补充道。
“这就是我们所说的死亡螺旋，”吉德瓦尼说。
吉德瓦尼的研究指出，即使补贴没有终止，未来十年纳税人也将承担约3500亿美元的补贴成本。
在放弃了依赖了11年的医保后，托比亚森夫妇不打算重返《平价医疗法案》医保市场。他们曾了解过一个基于信仰的医疗组织提供的替代方案，但最终决定不参保。
目前，他们没有后备计划。他们已经为医疗应急情况存了一笔钱。丽贝卡·托比亚森说，如果积蓄用完，他们还有最后两个求助途径：信用卡或家人。
你是否难以负担医保费用？你是否决定放弃医保？点击此处联系KFF健康新闻，分享你的故事。
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They’re uninsured after Obamacare became too costly. And they’re far from alone.
June 15, 2026 5:00 AM EDT / KFF Health News
Sugar Grove, North Carolina— Year after year, Ross and Rebecca Tobiassen saw their healthcare costs rise, having relied on the Affordable Care Act for federally subsidized health insurance since its start in 2014. Year after year, the couple in western North Carolina kept their coverage, believing the peace of mind was worth the cost.
But in December, that changed. The Tobiassens decided to cancel their insurance when Rebecca saw the cost of their monthly premiums would jump from $130 to more than $550.
“It makes no sense,” she said. “It’s not worth it anymore.”
Rebecca and Ross Tobiassen canceled their Affordable Care Act insurance last year when it became too expensive. Andrew Jones/KFF Health News
The couple own and are the only employees of a small auto shop just west of Appalachian State University in the North Carolina mountains. Rebecca worries about her husband, whose work as a mechanic can be dangerous. A spring once shot a metal ball joint into their garage wall like a gun. A heavy object crushed Ross’ thumb. In 2020, Ross became mostly blind in one eye after repeatedly getting metal shards in it and developing an infection in his cornea.
The Tobiassens are among the Americans who canceled their ACA coverage after Congress allowed enhanced tax credits that helped pay for insurance plans to expire at the end of 2025. The Tobiassens benefited from those tax credits — like millions of other enrollees expected to drop or be dropped from their coverage as the year progresses, unable to keep up with the higher costs.
Established by the Biden administration’s American Rescue Plan Act during the COVID pandemic, the expanded subsidies reduced monthly premiums for many families and prompted a tidal wave of new signups, doubling ACA enrollment to about 24 million.
The Centers for Medicare & Medicaid Services is expected to soon release complete data on how many people are no longer covered under the ACA, but an early analysis from KFF, citing Wakely Consulting Group research, showed enrollment could drop from over 22 million at the end of 2025 to as low as 16.5 million in 2026.
In North Carolina, individual ACA signups for 2026 were down 22% compared with the year before, a greater drop than any other state, amounting to a decrease of more than 213,000 people, according to enrollment data. While the Tobiassens’ two teenage daughters remain on Medicaid, Rebecca said the new prices showed that the federal government doesn’t care about families like hers.
“We’ve known that you don’t care about us,” she said, “but you’re making it plain and simple now.”
The couple’s insurance hadn’t helped them cover all their medical needs. When the pain from Ross’ eye infection worsened five years ago, Rebecca insisted he go to a specialist, who told them that fixing the eye through cornea replacement surgery would cost them up to $30,000 and require Ross to take six months off.
Ross chose a less expensive treatment to kill nerves in the eye instead.
The couple know they’re taking a risk by not being insured. If something were to happen, they could face an enormous medical bill.
Ross, 47, said the blindness in the one eye doesn’t significantly affect his job. He works long hours, sometimes into the night to keep up with demand.
“I try not to think about it too much,” he said. “I just work.”
Ross Tobiassen built his auto shop, which he owns with his wife, next to his home on his property in western North Carolina. Andrew Jones/KFF Health News
Katie Alexander oversees volunteers for Pisgah Legal Services, a western North Carolina nonprofit that helps low-income people secure health insurance. Alexander has helped North Carolina and Tennessee residents try to get ACA marketplace plans since Obamacare’s launch. She said she’s never seen anything like this year.
Nearly 100 Pisgah clients, out of about 700 that Alexander’s team worked with during open enrollment, decided to drop insurance this year, and many others chose cheaper ACA plans with less coverage, Alexander said.
Alexander said the people who have dropped their coverage include Lyft and Uber drivers. They’re trying to start their own businesses. They are artists and people who can work only part-time, because they’re chronically ill. Some are unable to get insurance through their employers, or they make too much to be on Medicaid.
“Even for folks who don’t have chronic illnesses,” Alexander said, “there’s just this nagging at the back of your mind, kind of constantly, of: ‘Don’t get hurt. Don’t get sick. Because you can’t afford that.’”
ACA premiums and deductibles steadily increased for years starting in 2022, then spiked during the enrollment period for 2026 plans, according to data analyzed by KFF. The Tobiassens have seen every dip and rise in plan costs since 2014 when the plans launched. They joined immediately and paid about $30 a month, Rebecca Tobiassen said.
“You actually felt like you were benefiting,” she said.
But through the years as the marketplace became more expensive, the couple made concessions, switching at one point from a silver plan — historically the most popular — to a bronze. The plan mostly provided for the couple’s basic needs.
As they saw their deductibles and premiums rise over more than a decade, Rebecca feared the day would come when they could no longer afford even the cheapest plan.
“Plans are unaffordable, no matter how you cut it,” said Risha Gidwani, a healthcare policy researcher at the University of Colorado Anschutz School of Medicine. “It’s just who is shouldering the unaffordability.”
Gidwani and health economist Cheryl Damberg, in a study published earlier this year, found that most bronze plans, the cheapest ACA options for many, would be unaffordable without subsidies for the average person using the federal healthcare coverage.
Without subsidies, many families using these plans don’t make enough to afford premiums or deductibles, Gidwani’s research shows.
People who drop health insurance also change what’s known as the “risk pool,” Gidwani said, when a group of people share financial hazards.
If healthier people drop out of the risk pool, fewer people subsidize the people who get sick, Gidwani said. That means premiums for the people who get sick will increase again in the future, she added.
“That becomes what we call a death spiral,” Gidwani said.
Even if the subsidies hadn’t expired, taxpayers would have borne an estimated $350 billion burden over the next decade to cover them, Gidwani’s study noted.
After dropping coverage they’d relied on for 11 years, the Tobiassens have no plans to return to the ACA marketplace. They looked into alternative options through a faith-based healthcare organization but decided to go without.
For now, they don’t have a plan B. They’ve set aside some money for a medical emergency. And if their savings run out, Rebecca Tobiassen said, they have a couple of last resorts to lean on: credit cards or family members.
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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.