New enrollments in Covered California, the state’s health insurance marketplace under the Affordable Care Act, are down by nearly one third over the past year across the San Joaquin Valley following the expiration of enhanced tax credits that helped subsidize the cost of coverage for buyers.
Cancellation of coverage by people who were previously enrolled, particularly middle-income individuals and households who benefited from the expanded COVID-era subsidies, are also up as people encounter higher out-of-pocket costs for premiums.
Almost 2 million California residents purchased health insurance through Covered California in 2025. The vast majority of those are people whose employers don’t provide health coverage to employees, self-employed business owners, freelance “gig economy” workers, and people who make too much money to qualify for Medi-Cal, the state’s incarnation of the federal Medicaid program for low-income residents. Under Covered California, people can purchase health insurance policies at different levels of coverage from an array of companies.
In the San Joaquin Valley (Fresno, Kern, Kings, Madera, Merced, San Joaquin, Stanislaus and Tulare counties), just over 22,000 people signed up for new Covered California plans during the open enrollment period for 2026, after the expiration of the Enhanced Premium Tax Credits on Dec. 31. That’s down 32% compared to 2025 open enrollment, when almost 32,400 people signed up.
The enhanced subsidies enacted during the COVID-19 pandemic to increase the affordability of the health plans for middle-income members expired at the end of 2025 with no congressional action to continue the relief. What that means is that the out-of-pocket cost for premiums increased substantially for members, especially those in middle-income families, according to a county-by-county analysis by the Public Policy Institute of California.
“During the pandemic, Congress temporarily increased subsidy amounts and expanded eligibility to middle-income households – those earning between 400% and 600% of the federal poverty level (about $62,000 to $94,000 for an individual or $128,000 to $193,000 for a family of four),” analysts Shannon McConville and Shalini Mustala wrote in the PPIC report.
The PPIC estimated the average annual premium for middle-income enrollees increased by more than $5,200 per person in Fresno County and more than $10,000 per person in Merced County.
In the San Joaquin Valley, Covered California reported that more than 161,000 Covered California enrollees benefit from some level of tax credit, mostly from the original subsidies for lower-income households included when the Affordable Care Act became law. The expiration of the expanded tax credits, however, leaves those in the middle-income range to largely bear the entire cost of premiums without any subsidy. Covered California reported that more than 17,200 members in the Valley are unsubsidized.
Cutting corners on coverage
Companies that offer health plans through Covered California sell different levels or tiers of coverage named for precious metals – platinum, gold, silver and bronze – as well as a basic minimum-coverage tier.
Platinum plans have higher monthly premiums, but provide more expansive coverage and lower deductibles – the out-of-pocket cost when a member visits a doctor, hospital or other health care provider. In each subsequent plan tier, the monthly premium drops but deductibles are generally higher, and the coverage may be less comprehensive.
As affordability of insurance premiums declines with the expiration of the enhanced tax credits, a marked shift is taking place among enrollees, as well as renewing members, who are selecting health plans that come with lower monthly premiums, but higher deductibles.
Statewide, changes in enrollment in the different tiers between 2025 and 2026 were:
- Platinum: 64,722 members in 2025, falling 10.8% to 57,720 in 2026.
- Gold: 119,891 members in 2025, falling 10.0% to 107,896 in 2026.
- Silver: 1,321,833 members in 2025, falling 10.6% to 1,181,687 in 2026.
- Bronze: 457,439 members in 2025, rising 23.4% to 564,476 in 2026.
- Minimum coverage: 13,264 members in 2025, rising 17.6% to 15,592 in 2026.
“This year’s open enrollment was unique for many reasons, amplified by the loss of the Enhanced Premium Tax Credits that have helped thousands of Californians pay for their monthly premiums,” Jessica Altman, Covered California’s executive director, said in a prepared statement. “Many Californians see the value in remaining covered, but they had to make sacrifices and shift to lower-tier plans.”
In addition, experts suggest that some people and households who earn too much to qualify for Medicaid, and are eligible to enroll in Covered California, are opting to simply go without any health insurance because they cannot afford the premiums or have prioritized other household costs including housing, food and utilities.
“The high cost of private insurance and limited availability of public coverage for some individuals with low income – particularly in states that have not expanded Medicaid under the Affordable Care Act (ACA) – continued to leave millions of people without health coverage in 2024 [the latest year for which official estimates of the uninsured are available],” researchers with KFF, an independent health policy, research and news organization, stated in a report earlier this month.
U.S. Census Bureau data indicates that as of 2024, more than 291,000 San Joaquin Valley residents had no health insurance at all – whether Medicaid or Medi-Cal for low-income people, Medicare for senior citizens, private health insurance, coverage through their employer or Covered California ACA exchange.
“The number of people who are uninsured is expected to continue to increase in coming years because of changes to Medicaid and the ACA Marketplace included in the 2025 reconciliation law, the expiration of the Marketplace enhanced premium tax credits and other administrative actions, the KFF authors added. “The Congressional Budget Office (CBO) projects that over 14 million more people will be uninsured in 2034 due to the combined effects” of changes in eligibility for both Medicaid and the ACA marketplace that were included in H.R. 1, the One Big Beautiful Bill Act backed by President Donald Trump and passed by Congress last summer, as well as with the expiration of the enhanced ACA tax credits.
KFF President/CEO Drew Altman, who is also the executive publisher of KFF Health News, wrote in an April 10 policy column that passage of the Affordable Care Act in 2010 helped reduce the number of uninsured Americans and put a spotlight instead on the overall affordability of health care.
“The uninsured is not the most politically salient problem in health care now – that’s affordability – nor is it the non-problem some say it is,” Altman wrote. “But it’s coming back. And the problem of the chronically ill uninsured is glaring.”
“People who are uninsured and have a major chronic illness need a lot of health care and use more prescription drugs with no financial protection,” he added. “They are part of a larger problem that has receded but will soon reemerge” as Affordable Care Act enrollment declines and federal cuts to Medicaid escalate.
Tim Sheehan is the Health Care Reporting Fellow at the nonprofit Central Valley Journalism Collaborative. The fellowship is supported by a grant from the Fresno State Institute for Media and Public Trust. Contact Sheehan at tim@cvlocaljournalism.org.