Florida ACA Exodus Shifts Health Costs to Hospitals and Employers

A coverage collapse with costs that spread

In June, 21-year-old Florida chef Elijah Button cut his middle finger to the bone while slicing onions. He treated it at home with a butterfly bandage, a splint and help from his uncle, because he could not afford emergency care.5 Button had dropped his Affordable Care Act plan in January after a $100 monthly premium increase that he could not cover.10 His case has become the opening image of Associated Press coverage of Florida's health insurance crisis, and it shows the core problem well. When people leave insurance, their medical needs remain, and someone still pays for the care they eventually get.

About 440,000 Floridians left Obamacare plans this year after enhanced federal subsidies expired in January. That is more than in any other state.16 Debate over those subsidies helped cause a record 43-day government shutdown last fall. Democrats pushed to extend the pandemic-era aid, and most Republicans opposed it.1 Almost a year later, Congress has passed no major law to lower health costs. The administration says it is tackling affordability through fraud enforcement and agreements with drug companies.1

Most coverage focuses on individual households. The bigger story is that costs are moving between groups. Some of the burden is shifting from federal subsidies onto hospitals, free clinics, small employers, and the Floridians who still have insurance.

Why Florida was the most exposed state

Florida has the largest ACA enrollment in the country. With just over 3.8 million enrollees, it makes up about one-fifth of national marketplace enrollment.1 Reporting points to two causes: the state's large construction, hospitality and small-business workforce, and the Republican-led legislature's decision never to expand Medicaid.120

The employer angle explains much of this. Only 40% of Florida's workforce gets health insurance through an employer, the lowest share of any state.12 Rep. Darren Soto, a Democrat whose district south of Orlando is near the theme parks, said his district had the second-largest ACA enrollment in the country, partly because many small tourism businesses cannot offer coverage.1 In much of the U.S., the marketplace supplements job-based insurance. In Florida it often takes the place of job-based insurance.

The enhanced credits turned that situation into record enrollment. One analysis puts Florida's pre-2021 marketplace enrollment at about 2 million and its 2025 enrollment at 4.74 million. It argues that the people who joined because of the subsidies were the most likely to leave once the subsidies ended.11

The numbers vary, but the direction is clear

The headline figures differ depending on what is being measured. CMS open-enrollment data released in February showed about 202,000 fewer Floridians signing up for 2026 plans, the second-largest drop after Georgia.16 Later effectuated-enrollment data, which counts only people who enrolled and paid their first premium, showed a 10% drop from 4.3 million to 3.85 million, or about 450,000 people.12 The gap matters. Advocates note that many people never formally cancel coverage. They simply stop paying.11

The sources disagree more about where those people went. KFF vice president Cynthia Cox said most of the roughly 443,000 Floridians who left are probably uninsured, because the marketplace is usually a "place of last resort."5 An analysis in The Conversation was more cautious. It noted that some people may have moved to a spouse's plan or a cheaper catastrophic policy, and that the full picture will not be clear until state uninsured rates come out in 2027. Nationally, it said, about 1 in 10 people who left the exchanges reported becoming uninsured.12 The federal Department of Health and Human Services offers a third view. Its June report said nearly 3 million subsidized enrollees lost coverage, and it argued that many recipients had high incomes or qualified for other programs such as Medicaid.12

Cox's reading fits Florida better than the national average does. The state that relies least on employer coverage and never expanded Medicaid offers few other options to people who leave the marketplace. The Florida Policy Institute projects the uninsured rate could rise from a record low of 10.7% to 16.7%.11

Staying insured often means less coverage

The enrollment drop leaves out a second group: people who kept coverage but now pay more for less. Tracy Rand, a 51-year-old mental health counselor in Leesburg, was facing an increase from $55 to $1,100 a month. She switched to a $160 plan with higher deductibles and copays.1 To afford it, she quit a doctoral program and cut back on groceries and social outings, and she says bankruptcy now worries her.5

National data show the same pattern. The share of enrollees choosing silver plans fell from 56.2% to 42.6%, and bronze plans, which are cheaper but cover less, rose from 29.9% to 39.6%.12 Average premiums after tax credits went from $113 to $178 a month.13 Insurers expect another year of double-digit premium increases.8

For 2026, Florida carriers filed an average pre-subsidy increase of 31.5%, compared with 7.5% the year before.29 One benefits consultancy lists Florida's 33% increase among the steepest of any state.28

Hospitals and clinics absorb the pressure

The hospital-cost argument goes like this. Uninsured people who delay care often end up in emergency rooms. Hospitals absorb those unpaid bills as uncompensated care and then try to recover them through higher prices for insured patients.11 Analysts writing in The Conversation describe a ripple effect. Financial pressure on hospitals and medical practices can lead to service cuts and closures, which makes care harder to get for everyone.12

The move toward high-deductible plans makes this worse. Industry analysts warn that thinner coverage raises patients' risk of medical bills they cannot pay and could increase hospitals' uncompensated care.13 Advisers to providers are telling hospitals to plan for more bad debt and harder collections, and to review their charity-care policies.1619 One revenue-cycle executive said insurance status is becoming a poor predictor of whether a patient will pay. Many insured patients now behave like self-pay patients.13

Florida's free clinics are seeing the first effects. Grace Medical Home in Orlando charges uninsured, low-income patients $5 a visit. It treated about 1,350 people last year and recently added a mobile acute-care clinic to handle demand.5 Its chief executive, Stephanie Garris, said Florida's roughly 110 free and charitable clinics cannot meet the need, and that doubling or tripling her own capacity is not realistic given how many people are uninsured.5

Employers face their own cost increases

The marketplace changes also affect employers. Because the ACA sets required benefits for small-group plans, small-employer rates in Florida rose too. State regulators' data showed average per-person small-group costs going from $728 in 2025 to $821 in 2026.23 That increase is much smaller than the one individuals faced, but it adds pressure on the small tourism and service businesses that already have trouble offering coverage.

Larger employers are also seeing rising costs. Mercer projected that health benefit costs per employee would rise an average of 6.5% in 2026 even after cost-cutting, the largest increase since 2010. Without changes, the increase would be closer to 9%.30 To manage this, 59% of employers said they would raise deductibles and copays, which shifts costs to workers.30 A newer Marsh analysis projects an 8% rise in per-employee benefit costs for next year.22 Florida's own state employee health plan raised its projected medical claims, which led to a combined $442.9 million increase in forecast expenses over five years.24

The drivers in employer coverage and the marketplace are similar. Insurers point to higher costs and greater use of services.21 One consultancy argues that hospital consolidation in Florida has weakened insurers' bargaining power and raised network rates.28 That is a vendor's view, but it fits the broader pattern. Hospitals that take on more uncompensated care have reason to push for higher rates from commercial payers, and those rates show up in employer premiums.

What comes next

Health costs have become a central issue in Florida's midterm races. Republicans are emphasizing fraud crackdowns, and Democrats say a change in control of Congress would bring back the subsidies.1 Soto's Republican opponent, Dan Green, did not respond to questions about the subsidies and has focused on grocery and property-insurance costs.5

In the near term, open enrollment gives people who dropped coverage a chance to come back without penalty.11 But premiums are expected to rise again, and the subsidies are still gone, so many of those who left are unlikely to return. Florida, with its low employer coverage and no Medicaid expansion, shows the consequences most clearly. Ending the subsidies did not remove the cost of care. It moved that cost onto hospitals, clinics, employers, and insured patients who pay more through higher premiums.