Open enrollment for plans offered under the Affordable Care Act begins Saturday, and for many Americans the window to sign up or switch plans will come against the backdrop of rising premiums. Millions are expected to see higher monthly costs, intensifying long-standing tensions between coverage gains under the law and the persistent problem of affordability.

For individuals who buy their own insurance on the marketplaces, open enrollment is the principal opportunity each year to obtain coverage, change plans or reassess financial assistance. When premiums rise, families and individuals who rely on marketplace plans confront stark choices: pay more for care that can become unaffordable, choose less comprehensive coverage, or forgo insurance altogether. Public health experts warn that even modest premium increases can lead people to delay care, skip medications, and accumulate medical debt — outcomes that worsen chronic disease management and increase downstream costs to hospitals and communities.

The premium pressures come amid uneven markets across the country. In many rural counties, a shrinking pool of insurers has left consumers with few plan options and limited competition to hold down prices. Low-income residents in states that have not expanded Medicaid remain particularly vulnerable; those earning too much for Medicaid but not enough to comfortably absorb increased premiums can fall into coverage gaps that aggravate health inequities. Communities of color, where underlying rates of chronic illness are higher due to structural determinants of health, are likely to feel the impact more acutely.

Local community health centers, consumer assistance programs and federally funded navigators play a critical role during open enrollment, helping residents understand eligibility for subsidies and select plans. But those resources vary widely by region and are often underfunded, leaving populations with limited internet access, language barriers or irregular work schedules at higher risk of missing enrollment deadlines or choosing plans that do not meet their needs.

Rising premiums also pose a political and policy test. State and federal lawmakers face pressure to pursue options that could blunt cost increases, including expanding Medicaid, strengthening consumer protections, investing in reinsurance programs, or bolstering premium tax credits for lower- and middle-income households. Health policy analysts note that short-term measures may ease immediate burdens, but lasting improvements will require addressing the underlying drivers of health care costs, including prescription drug prices, provider consolidation, and regional disparities in care supply.

Public health officials stress the community consequences of reduced coverage. Uninsured populations are more likely to defer preventive care, leading to later diagnoses and more resource-intensive care in emergency settings. That dynamic increases strain on safety-net hospitals and community clinics, which are often already operating with thin margins.

As enrollment begins, advocates are urging people to check their eligibility and shop marketplace plans carefully, while calling on policymakers to prioritize both access and affordability. For millions, the next few weeks could determine whether they keep health coverage that allows them to manage conditions, seek preventive services, and avoid financial hardship — outcomes that ripple across households and communities.