The Elephant in Every Entrepreneur's Room: Health Insurance in 2026
Happy New Year. Now let's talk about the thing nobody wants to talk about.
If you're self-employed, a small business owner, or a freelancer who's been relying on the ACA marketplace for health insurance, you already know. The enhanced premium tax credits expired at midnight on December 31st. And for millions of us, that means everything just changed.
The numbers are brutal. Nearly half of all adults with ACA marketplace coverage are self-employed entrepreneurs, small business owners, or work for small businesses. That's not a niche, that's almost half of the marketplace. And now, without the enhanced subsidies that have been in place since 2021, premiums are expected to more than double for many of us.
We're talking about entrepreneurs seeing their monthly premiums jump from $340 to nearly $2,000. From $625 to $2,670. From $0 to $275 -for someone who couldn't afford the $275 in the first place.
These aren't hypothetical numbers. These are real people who are now making the impossible calculation: health insurance or rent? Coverage or payroll?
This is a small business issue. Let's be clear about something. This isn't just a "healthcare policy" issue. This is a small business survival issue.
When health insurance becomes unaffordable, entrepreneurs don't just lose coverage; some lose the ability to take the risk of entrepreneurship at all. How do you leave a job with benefits to start a business when marketplace coverage costs more than your mortgage? How do you hire employees when you can't even cover yourself?
The system is essentially telling entrepreneurs: go get a job so someone else can insure you. That's the opposite of what we should be incentivizing.
What are your options now? I'm not going to sugarcoat it; there are no perfect solutions. But there are options worth exploring:
1. Shop the Marketplace anyway: Open enrollment runs through January 15th in most states. Subsidies still exist - they're just reduced. Your income, location, and family size all factor in. Use a broker (they're free) to help you navigate. Don't assume you don't qualify for anything.
2. Health Sharing Ministries: These are not insurance -let me be clear about that. They're communities where members pool money to share medical costs. They're significantly cheaper (often 30-50% less), but they come with restrictions: pre-existing conditions may not be covered, and there's no legal guarantee your expenses will be paid. Names to research: Zion HealthShare, Christian Healthcare Ministries, Medi-Share, or secular options like Sedera.
3. Direct Primary Care (DPC) + Catastrophic Coverage: Some entrepreneurs are unbundling their healthcare entirely. You pay a flat monthly fee ($60-$100) directly to a primary care doctor for unlimited visits and basic care, then pair it with a high-deductible catastrophic plan for emergencies. It's not for everyone, but it's worth understanding.
4. Association Health Plans: Some professional associations and organizations offer group health plans to members. If you belong to a trade association, chamber of commerce, or professional group, ask what's available.
5. HSA + High-Deductible Plan: If you're generally healthy and can handle higher out-of-pocket costs, pairing a Health Savings Account with a high-deductible plan lets you save pre-tax dollars for medical expenses. The money rolls over year to year.
6. Spouse's Employer Plan: If your spouse has access to employer-sponsored coverage, now might be the time to get on it.
What I need you to understand is that none of this is ideal. Health sharing isn't insurance. High-deductible plans mean you're paying thousands before coverage kicks in. And the marketplace, even with reduced subsidies, may still be unaffordable for some.
But here's what I refuse to accept: the narrative that entrepreneurs should just give up and go get jobs because the system isn't built for us. The system should be built for us. Nearly 40% of American businesses are owned by women. We're creating jobs, serving communities, and driving the economy. And we deserve access to affordable healthcare that doesn't require choosing between coverage and keeping the lights on.
Congress may vote on extending the subsidies in January; nothing is final yet. In the meantime, do your research, talk to a broker, and make the best decision you can with the information you have.
And keep talking about this. The more noise small business owners make, the harder it is for legislators to ignore us. This is the work. Let's keep going.