How do chronic illnesses like diabetes affect insurance costs post-ACA?
Executive summary
The Affordable Care Act (ACA) largely eliminated medical underwriting for pre‑existing conditions, so people with diabetes cannot be denied coverage or charged more solely for the condition, and many marketplace plans include diabetes‑specific benefits such as $0 insulin or diabetes management services [1] [2]. However, out‑of‑pocket burdens—high deductibles, copays, coinsurance—and broader policy changes (expiring enhanced premium tax credits and new federal budget rules) are pushing total costs up for people with chronic illnesses, and uninsured or moderately insured patients still face large insulin and care expenses [3] [4] [5] [6].
1. The baseline change: no denials or rating up for pre‑existing conditions
Since ACA marketplace plans began in 2014, insurers cannot deny coverage or charge higher premiums because someone has diabetes; that protection is central to why many people with chronic illness buy marketplace plans [1]. This is the structural reason diabetes patients gained more reliable access to insulin, supplies, and diabetes care after the ACA was implemented [6] [1].
2. Cost components that still hit people with diabetes
Coverage does not mean low cost. Marketplace enrollees with diabetes can face substantial out‑of‑pocket (OOP) burdens driven by deductibles, copayments, and coinsurance—especially in plans with lower premiums and higher cost‑sharing. A peer‑reviewed study found variation across states and that OOP costs remain a disproportionate burden for moderate‑income people with diabetes [3]. The American Diabetes Association also notes that an insured person who requires insulin can incur extra costs exceeding about $4,800 per year beyond premiums in some analyses [7].
3. Insulin and drug prices: insured people helped, uninsured still vulnerable
Post‑ACA insurance expansion reduced the uninsured rate among adults with diabetes, but high insulin prices remain a major driver of financial strain. Research shows insured individuals’ insulin OOP payments were relatively stable, while uninsured people saw much larger increases, exposing them to dangerous rationing risks [6] [8]. That divergence matters because loss of coverage or gaps can quickly convert an insured person’s predictable costs into unaffordable ones.
4. Marketplace design and plan choice matter for people with chronic illness
Marketplace plans are benchmarked by metal level (bronze–platinum) and differ by premium versus deductible tradeoffs. Studies and advocacy groups emphasize that high‑deductible plans (common in private markets) shift more cost to enrollees when they actually use services—exactly the pattern that disadvantages people with chronic disease who need frequent care and medications [3] [7]. UnitedHealthcare and other insurers now advertise diabetes‑friendly benefits like $0 insulin on some ACA individual plans, but plan availability and specific drug and device coverage vary by state and by insurer; consumers must review plan documents [2].
5. Policy changes are amplifying cost risk for 2026 and beyond
A key driver of near‑term cost increases is the scheduled expiration of enhanced premium tax credits at the end of 2025 if Congress does not act; insurers and analysts say that assumption is already built into 2026 rate filings and could raise premiums and overall costs for millions [4] [9]. Advocacy and policy analysts warn that rescinding or cutting subsidies will make ACA marketplace coverage much more expensive for people with diabetes who rely on these plans or who lack employer or Medicaid coverage [5] [10].
6. Insurer cost drivers: new drugs and utilization mix
Insurers cite rising utilization of high‑cost drugs—GLP‑1 class medications in recent filings—as one element raising trend lines used to set premiums; carriers expect script mix and utilization to grow, which can translate into higher premiums unless offset by subsidies or other policies [4]. The resulting premium pressure compounds the existing OOP cost problem for patients with chronic conditions.
7. What this means for patients and policy choices
For an individual with diabetes, the ACA’s key protections keep coverage accessible (no denial or higher rating) and have extended coverage to many who were previously uninsured [1] [6]. But whether that coverage is affordable depends on plan design, state‑level market offerings, drug formularies, and federal subsidy policy—factors that affect monthly premiums and the meaningfulness of “$0 insulin” marketing claims [2] [3] [4]. If enhanced subsidies lapse, many with chronic illnesses could face sharply higher premiums and OOP exposure [10] [9].
Limitations: available sources focus on diabetes and marketplace mechanics; they do not quantify every subgroup’s exact premium or total annual cost under every scenario. For specific premium estimates, the KFF Marketplace calculator and insurer plan documents are recommended [11] [2].