If you were denied Medicaid or earn just above the cutoff, you still have real options ā but 2026 changed the math. The enhanced ACA subsidies that made marketplace plans cheap for four years expired on December 31, 2025, and the āsubsidy cliffā at 400% of the federal poverty level is back. That means marketplace coverage got more expensive for many people this year, and for some it became unaffordable overnight. Hereās whatās actually available, what it costs now, and where to get care if insurance is out of reach.
Why Marketplace Coverage Costs More in 2026
From 2021 through 2025, enhanced premium tax credits removed the 400% FPL income cap and capped what anyone paid for a benchmark plan at 8.5% of income. Those enhancements lapsed at the end of 2025 and subsidies reverted to their original rules on January 1, 2026.
Two consequences matter:
The subsidy cliff returned. Earn one dollar over 400% of FPL and you now get no premium tax credit at all. Not a reduced one ā none. For a household near that line, a small raise or a bonus can cost thousands.
Premiums rose for people who still qualify. Subsidies below 400% FPL still exist, but theyāre smaller than they were in 2025. Projected marketplace enrollment fell from about 22.3 million in 2025 toward roughly 17.5 million in 2026, largely because of cost.
One thing that did not change: cost-sharing reductions. If your income is under 250% of FPL and you pick a Silver plan, you still get lower deductibles and copays. Those are separate from the expired premium credits and remain available. If youāre in that income range, Silver is usually the right tier even when Bronze looks cheaper monthly.
Check Whether Youāre in the Coverage Gap First
Ten states still havenāt expanded Medicaid. In those states, adults earning below 100% of FPL can fall into the coverage gap: too much income for that stateās narrow Medicaid rules, too little to qualify for marketplace subsidies, which start at 100% FPL.
If thatās you, marketplace plans generally wonāt be subsidized, and the realistic path is the free and sliding-scale care described further down. Itās worth confirming your stateās expansion status before assuming you donāt qualify ā several states expanded recently.
Coverage Options Ranked by What Most People Should Try
1. Re-check Medicaid and CHIP
Medicaid eligibility isnāt only about income. Pregnancy, disability, age, and household size all change the calculation, and some states have separate pathways (medically needy, spend-down, waivers) for people over the standard limit. If you have children, CHIP covers kids at considerably higher income levels than adult Medicaid ā in many states well into middle-income territory. Your kids may qualify even when you donāt.
2. The ACA marketplace, with a Silver plan if youāre under 250% FPL
Run your actual numbers at HealthCare.gov rather than assuming. Even with reduced subsidies, many households still qualify for meaningful help. If youāre near the 400% cliff, note that pre-tax retirement contributions lower the modified adjusted gross income the marketplace uses ā sometimes enough to move you back under the line.
3. Employer or family coverage you may have overlooked
A spouseās or parentās plan (you can stay on a parentās plan until 26), COBRA from a recent job, or a part-time employer plan. COBRA is expensive but keeps your existing doctors, and it has a 60-day election window after coverage ends.
4. Medicare, if you qualify
Medicare isnāt only for people 65 and older. It also covers people under 65 who have received Social Security Disability Insurance for 24 months, and people with ESRD or ALS. If a disability determination is in progress, this may be your path.
Where to Get Care Without Insurance
If coverage genuinely isnāt affordable, care is still available. These are the workhorses.
Federally Qualified Health Centers (FQHCs). Community health centers must offer a sliding fee scale based on income, and they cannot turn you away for inability to pay. They handle primary care, chronic disease, dental at many sites, behavioral health, and prescriptions. Find one at findahealthcenter.hrsa.gov. For most uninsured people this is the single best starting point.
Hospital charity care. Every nonprofit hospital is federally required to maintain a financial assistance policy. Under roughly 200% of FPL often means full forgiveness; 200ā400% typically means a sliding discount. Apply before a bill goes to collections if you can, though itās often still possible after.
Free and charitable clinics. Volunteer-staffed clinics operate in most states, and Remote Area Medical (RAM) runs large free pop-up clinics offering dental, vision, and medical care with no ID or insurance required.
Prescription assistance. Manufacturer patient assistance programs cover many brand-name drugs for people who are uninsured or underinsured. Search across manufacturers at NeedyMeds or RxAssist. Also compare cash prices ā for generics, a discount card at the pharmacy counter sometimes beats an insurance copay.
Title X and community reproductive health clinics for family planning and screenings on a sliding scale.
Options to Approach Carefully
Short-term limited-duration plans and health care sharing ministries are marketed heavily to people priced out of the marketplace. Both are cheaper for a reason: they are not ACA-compliant. They can exclude pre-existing conditions, cap benefits, decline to cover prescriptions or maternity care, and sharing ministries are not insurance and carry no legal obligation to pay your claims. They can make sense as a short bridge between jobs. They are a poor fit if you have an ongoing condition.
Alternatives to Medicaid FAQs
What can I do if I make too much for Medicaid?
Check the ACA marketplace first ā subsidies still exist below 400% of FPL, and a Silver plan adds cost-sharing reductions under 250% FPL. If coverage is still unaffordable, use a federally qualified health centerās sliding fee scale, hospital charity care, and prescription assistance programs.
Did ACA subsidies really end in 2026?
The enhanced subsidies expired December 31, 2025. Regular premium tax credits still exist for households between 100% and 400% of FPL, but theyāre smaller, and above 400% FPL thereās now no subsidy at all.
What is the Medicaid coverage gap?
In the ten states that havenāt expanded Medicaid, adults under 100% of FPL can earn too much for Medicaid but too little for marketplace subsidies, leaving them with no affordable coverage option. Free clinics and FQHC sliding scales are the practical fallback.
Can my kids get coverage if I donāt qualify?
Often yes. CHIP covers children at much higher income limits than adult Medicaid, so children frequently qualify in households where the parents donāt.
Where can I see a doctor with no insurance and no money?
A federally qualified health center ā they use a sliding fee scale and cannot refuse you for inability to pay. Find one at findahealthcenter.hrsa.gov. Free and charitable clinics and RAM events are additional options.
Are short-term health plans a good substitute?
Only as a temporary bridge. They arenāt ACA-compliant, so they can exclude pre-existing conditions and cap or deny benefits. Theyāre a poor choice if you have an ongoing medical condition or take regular prescriptions.
