Missourians are increasingly opting for lower-cost health insurance plans that come with higher out-of-pocket expenses, as rising premiums continue to strain affordability in the Affordable Care Act marketplace.
About half of all Missouri enrollees chose bronze plans in 2026 — the lowest-premium option with the highest deductibles — a significant shift from last year, when mid-level silver plans were the most popular. In 2025, roughly 55% of enrollees selected silver plans, compared with about 37% this year. Meanwhile, bronze plan enrollment grew to around 180,000 Missourians, about 35,000 more than the year before.
The shift comes as costs continue to climb. On average, Missourians are paying nearly $1,200 more per year for marketplace plans in 2026 — a 17% increase from last year, and slightly below the national average increase of about 20%.
At the same time, enrollment has declined. Data from the Centers for Medicare and Medicaid Services show about 10% fewer Missourians signed up for marketplace coverage this year.
The move toward bronze plans mirrors a broader national trend, but the change is more pronounced in Missouri. Nationwide, bronze plan selection rose by about 10 percentage points while silver plan enrollment dropped by 14 points. In Missouri, the number of customers choosing bronze plans increased by 15 percentage points and silver plan enrollees fell by 18 points.
“The main reason premiums are lower is that they don’t cover as much health care,” said Washington University health policy professor Timothy McBride. “These plans have higher deductibles and copayments, which can make it harder for people to actually use their coverage.”
One reason for the shift is the lapsing of increased, Biden-era subsidies which made costs lower for buyers. But even as federal subsidies increased in recent years, they did not keep pace with increases in premiums charged by insurance companies.
The larger subsidies had been criticized by Republicans who saw them as a handout. But advocates said removing them would lead some relatively healthy people – who might think they could afford to forego insurance – to leave the marketplace. That, in turn, would make the overall population in need of more care, on average, which analysts said could lead to another, corresponding increase in premiums as insurance companies hedged their financial risk.
Even though enrollees who qualified for financial assistance received an average of $173 per month this year—up from $91 last year—out-of-pocket premium costs still surged by about 90%. That’s well above the national increase of 57.5%, leaving many Missourians paying nearly double what they did just a year ago.
That growing financial burden may already be affecting coverage stability. Recent data show that nationwide about 1 in 7 ACA enrollees missed their first month’s premium payment.
McBride said higher out-of-pocket costs can discourage even people with insurance from seeking routine care, potentially pushing more patients into emergency rooms and further increasing financial pressure on hospitals, which are disallowed by federal law from turning patients away, regardless of ability to pay, if they’re in urgent need of care.
“Hospitals are struggling in Missouri and elsewhere, especially in rural areas,” McBride said. “If patients can’t pay, that becomes bad debt. Hospitals have to absorb those costs, which can lead to higher prices or fewer services.”
Some providers say they are already seeing the effects. Randy Tobler, who operates a direct primary care clinic in Columbia, said more patients are turning to alternative care models because they cannot afford to use their insurance for everyday services.
“We can provide a lot of services that would otherwise be out-of-pocket before someone meets their deductible. Under a membership model, much of that is covered,” Tobler said. “We’re also seeing people whose premiums have gone up — they’re holding onto insurance just for catastrophic coverage.”
McBride’s analysis shows affordability challenges have especially affected rural parts of the state. About 10% of rural Missourians lack health insurance, compared with 6.9% in urban areas — a gap far wider than the national difference of about 0.6 percentage points.
McBride said limited provider availability and less competition in rural areas contribute to higher premiums and fewer affordable options, disproportionately affecting older and lower-income residents.
“The simplest way to put it is availability of providers. There's not as much competition for providers in rural areas in these plans,” he said. “So the only things that really matter are age, income relative to poverty, and where you live. And it turns out that the premiums vary enormously on all three of those characteristics.”
He said the trend disproportionately affects low-income and older residents in rural areas, undermining the Affordable Care Act’s primary goal of expanding access to affordable coverage.
