A founder’s hypothesis — first in an ongoing series
Let me say the quiet part out loud: the enhanced ACA premium tax credits expiring at the end of 2025 wasn’t a policy hiccup. It was a signal.
The individual marketplace is mid-restructuring, and most of the industry is still talking about it like it’s a temporary storm to wait out.
It’s not a temporary storm. It’s a permanent shift.
Here’s my hypothesis on the future of ACA, and where I think we go from here.
The Subsidy Cliff
The numbers are already public. The enhanced credits — in place since 2021 — expired January 1, 2026.
KFF estimates the average enrollee’s premium contribution jumped roughly 114%, an extra $1,000-plus a year for a typical household.
A family of four earning around $130,000 saw their monthly premium roughly double, from about $921 to nearly $2,000.
Older, middle-income enrollees got hit hardest — the so-called subsidy cliff at 400% of the federal poverty line came right back.
The point is that this fight — subsidize more, subsidize less, who bears the cost — is going to keep happening.
Every year, every renewal cycle, it’s back on the table.
And every time it happens, it pushes the market a little further toward something structurally different than the ACA marketplace we’ve operated in for over a decade.
Insurance Carriers Will Be OK
Look at what’s actually happening in the market right now, not just what people are saying about it.
UnitedHealth is projecting roughly 500,000 people will disenroll from its ACA marketplace plans in 2026 — and raised its full-year profit forecast anyway.
Centene’s stock is up over 60% year-to-date. Elevance, Humana, Molina — all recovering, all guiding higher.
None of this is a coincidence, and none of it requires a villain.
Insurance companies are good at one thing above all else: pricing risk.
When subsidies shrink, healthier, more price-sensitive people are the first to walk away — coverage stops being worth the cost to them.
What’s left in the pool skews toward people who need care regardless of price.
Carriers see that coming and price for it. That’s not a conspiracy. That’s just what happens to a risk pool when the exit is labeled “too expensive.”
I’ll say this too, because it matters: carriers aren’t passive bystanders in this policy fight.
They lobby, they contribute to campaigns on both sides of the aisle, and they have real influence over what gets extended and what doesn’t.
I’m not saying that to villainize them — I’m saying it because pretending the policy fight happens in a vacuum, without carriers at the table, isn’t seeing the market clearly either.
From a carrier’s seat, stability and predictable risk are the goal.
I get why they’d rather have a market that sorts itself into cleaner risk categories than one that lurches every open enrollment based on the political weather.
Not saying that’s good or bad for consumers. I’m saying it’s rational — and if we don’t acknowledge that, we’re not seeing the market clearly.
Two Risk Pools: High and Low
Here’s where my hypothesis gets specific. I think we’re watching the early iterations of the individual market splitting into two distinct pools.
Pool #1 – Looks like level-funded, small-group-adjacent coverage.
Healthy people feel like they’re subsidizing everyone else on a traditional ACA plan, so this segment peels off into something that looks and prices more like small-group — employer or quasi-employer sponsored, underwritten with real actuarial discipline, healthier and more price-sensitive by design.
But this pool comes with real plumbing problems most of the industry hasn’t worked out yet.
Level-funded plans run on stop-loss coverage, and stop-loss underwriters aren’t set up to process individual-market volume the way small-group carriers are — that’s a different risk model, different paperwork, different relationships.
Most brokers selling ACA plans today have never quoted a stop-loss case in their life. That’s not a knock, it’s just true — and it means broker education becomes a bottleneck, not a footnote.
And nobody’s answered the basic operational question yet: is this sold through the same enrollment portal people already use for ACA plans, or does it need its own infrastructure entirely? Right now the honest answer is “it depends who you ask.”
Pool #2 – Looks more like a public-leaning, higher-risk pool — closer in spirit to Medicare Advantage than to the ACA marketplace most of us grew up selling.
Subsidized, yes, but built around the assumption that enrollees have ongoing health needs, not the assumption that they might churn out if premiums get inconvenient.
This pool has its own version of the same problem: it needs a support infrastructure built for people who will use their coverage regularly, not a system designed around annual open enrollment and hoping people stay healthy enough not to call.
If I’m right, the “individual marketplace” stops being one market with one set of rules and becomes two markets with two very different economics — and two very different sets of infrastructure nobody’s fully built yet.
Industry Parallels
I was in real estate long enough to watch the internet do to that industry what AI is about to do to ours.
Listings went online — Zillow and Redfin put every home’s price history in front of buyers before an agent ever picked up the phone.
Commissions got scrutinized, then litigated, then renegotiated. Buyers showed up to appointments having already done more research than some agents had.
The agents who survived didn’t out-hustle the shift. They specialized. They became the go-to person for luxury listings, or new construction, or first-time buyers who needed real hand-holding through a process that terrified them.
And they adopted the tools instead of resenting them — using the same data buyers had access to, but adding judgment the algorithm couldn’t.
The agents who didn’t adapt didn’t get eased into retirement. They got made irrelevant, fairly quickly, by people who saw the shift coming and moved first.
I think health insurance brokers are standing exactly where real estate agents stood a decade ago. Learn the tools and specialize, or watch the market do it without you.
Less Admin. More Consulting.
AI and workflow automation are already capable of handling most of what used to justify an agency’s headcount — enrollment paperwork, renewals, compliance tracking, routine support tickets.
That work is disappearing as a value driver, not because it stopped mattering, but because it stopped requiring a human.
What’s left is the part that actually requires expertise: knowing which plan design makes sense for someone managing a chronic condition, understanding formulary tiers well enough to save a client real money, being someone a client trusts enough to call before they panic-Google their diagnosis.
That’s a consultative skill set, not an administrative one. And it’s in short supply.
Small Agency vs. Big Fish
Here’s my honest belief, and it’s admittedly self-serving: a subject-matter expert with brand authority, an automated back office, and 1,000 lives is worth more than a twenty-person agency that writes policies all day with no point of view.
Size used to be the moat. I don’t think it is anymore.
Specialization plus automation is the new moat, and it’s available to a one-person operation in a way it never used to be.
That’s the bet we’re making at BenZen.
We picked a lane — health insurance for people navigating diabetes — and built the back office, content automation, and expertise to be the destination in that lane, rather than the passenger in a commodity business.
This Is My Hypothesis, Not a Prophecy
I want to be honest about what this post is. It’s a founder’s read on where the puck is going, not a certainty.
Congress has the power of the purse. More jurisdictions could create their own state based marketplace and set of rules.
The risk pools could evolve differently than I’m expecting. I’ll be wrong about some of this, and I’ll say so when I am.
But I’d rather stake out a position and be wrong in public than wait around for the market to finish restructuring before I say anything useful about it.
That’s the whole premise of this series — I’ll keep building on this hypothesis as the picture gets clearer, and I’d rather you hear it from someone willing to commit to a view.
More to come.
Information is meant to be accurate and educational and not intended to be legal, medical or financial advice.
Owner, Founder, BenZen Insurance. Built a solo health insurance media & tech company from the ground up. Doing his part to help people navigate a broken system.