In Boise, Idaho, Joshua and Ashley Durham have made the uncommon decision to go without health insurance for their family amid rising costs. Since launching their family medicine practice in late 2023, the Durhams initially purchased coverage through the Affordable Care Act (ACA) marketplace. However, with monthly premiums escalating to nearly $1,600 this year—several hundred dollars higher than the previous year—they have opted instead to pay out-of-pocket for medical expenses, relying on a $50,000 health savings account they accumulated over several years.
“We’re financially prepared, but it’s nerve-racking,” said Joshua Durham, a primary care physician. He acknowledged the risks of not having insurance, including exposure to large, unexpected medical bills. Despite their medical backgrounds, Joshua and Ashley have shifted their approach, with Joshua treating minor issues within the family and Ashley handling prescriptions. Their approach reflects a growing challenge among small healthcare providers as insurance premiums climb.
Health care workers generally have higher rates of insurance coverage than the broader population: 93 percent of healthcare workers were insured in 2024 compared with 89 percent of all adults under 65, according to a recent analysis. Physicians are among the least likely to forgo insurance, with only 2 percent uninsured. However, rising premiums are prompting even healthcare professionals to reconsider coverage. Employers and independent practices face steep premium increases, with forecasts predicting an 8.2 percent rise for 2027.
The expiration last year of certain pandemic-era ACA marketplace subsidy enhancements, implemented during the COVID-19 public health emergency, significantly affected affordability. While subsidies remain available for low-income enrollees, independent medical practices and small business owners, many of whom purchase plans on the marketplaces, no longer benefit from previous credits. Nearly half of ACA marketplace enrollees in 2024 were self-employed or worked for small businesses, including professionals in chiropractic and dental fields.
Jack Dillon, executive director of the Association for Independent Medicine, which represents over 4,000 physician-led practices, characterized these premium increases as “astronomical.” He noted that small healthcare employers may increasingly seek alternatives to traditional insurance offerings, potentially shifting toward higher wages or minimal plan coverage to manage costs.
For some healthcare workers, insurance remains essential despite mounting costs. Samantha LeGault, a nurse practitioner in Boise with chronic illnesses in her family, absorbed a premium increase from $700 to $1,500 a month. To manage the financial strain, she forgone dental insurance and prioritized costs elsewhere, including switching her children to public school and limiting retirement savings.
Others struggle with high deductibles and creeping costs. Retired health care executive Jill Kordick from Iowa, who once benefited from enhanced ACA tax credits paying $75 monthly, now faces premiums of $800 after credits expired. She has delayed necessary care due to the deductible and tight budget constraints, reflecting the economic burdens experienced even by those familiar with the healthcare system.
The Durhams have incorporated leniency for patients facing financial hardship into their practice, sometimes writing off balances instead of pursuing collections. Yet, Joshua Durham expresses persistent concern about unforeseen medical emergencies without insurance. The couple has spent approximately $9,000 this year from their health savings account on various treatments and therapies, a sum still substantially lower than projected insurance premiums.
Experts note that as healthier individuals opt out of coverage, insurance pools shrink and premiums rise, exacerbating affordability issues. The Congressional Budget Office estimates an increase of roughly 15 million uninsured Americans over the next decade, influenced by subsidy expirations and reductions tied to recent federal health legislation.
As medical professionals like the Durhams and others navigate an increasingly expensive health insurance climate, the challenges underscore broader trends affecting small healthcare providers and workers nationwide.