Stacy Cox has always prioritized having access to health insurance. For the 48-year-old self-employed photographer in southern Utah, it’s necessary “so that I can help to calm my anxiety and know that if I need care, I can get care.”

Still, Cox and her husband, John, have decided this month to go uninsured after the cost of their health plan under the Affordable Care Act skyrocketed.

At the end of 2025, Congress let enhanced premium tax credits that had helped bring down the cost of the couple’s ACA coverage expire. They were quoted $2,168.68 a month for the same plan that had previously cost them just under $500 a month. 

It was a “nerve wracking” decision, Cox said. Health insurance has helped keep the couple’s preexisting conditions under control. Cox has an autoimmune disease that requires prescription medication and extra medical care. She is also at a high risk for breast cancer and uses preventative services like more frequent mammograms. John, 55, had a quadruple bypass surgery in his late 30s that has required daily prescription medication. He also has annual check-ins with a cardiologist.

“For the most part, we’re healthy middle-aged people, but we’re also middle-aged, which means that every time we wake up, something else hurts or something stops working,” she said.

The enhanced subsidies, which were approved in 2021 at the height of the pandemic and later extended, were aimed at making ACA coverage more affordable to a larger group of people. They helped ACA sign-ups soar, with open enrollment roughly doubling since then. Cox had held out some hope that this current iteration of Congress would have taken some action by Thursday — the deadline in most states for people to enroll or renew ACA plans — to keep the enhanced tax credits.

That did not happen.

While the House passed a three-year subsidy extension on January 8 with the support of all Democrats and 17 Republicans, GOP lawmakers who control the Senate immediately shot down talk of approving the measure. President Donald Trump, who released a health care plan on Thursday with vague details to lower ACA premiums, also told reporters that he might veto the bill if it reaches his desk.

Preliminary data on ACA enrollment shows 22.8 million people have signed up for 2026 coverage so far — about 800,000 fewer people compared to this time last year. Experts say it could take months of emerging data to see the full scope of impact.

Cox has been self-employed since 2022, and losing her health insurance coverage raises a lot of logistical questions about what comes next. Will she eventually close her small photography business to find an employer that offers private health insurance? Would she have time for photography, even as a side gig? Could such a career pivot force the couple — her husband is also self-employed — to move out of Utah to find more job options?

“I don’t want our lives to drastically change because of this,” she said. “That’s what I’m afraid of.”

Women like Cox stand to lose major professional gains amid the cuts to ACA.

Prior to the enactment of the health law in 2010, many Americans were caught in “job lock” — stuck in careers and workplaces primarily because they offered private health insurance, which people with preexisting conditions often couldn’t access otherwise.

This was particularly tricky for small businesses and self-employed people who needed to purchase health insurance on their own. The ACA changed that: By 2022, small business owners and self-employed people represented 18 percent of marketplace coverage for workers between the ages of 21 and 64, according to a 2024 federal analysis. 

“The Affordable Care Act has given a number of small business owners or self-employed people or gig workers a kind of flexibility to be able to have that type of income,” said Cynthia Cox, a vice president at KFF, a nonprofit health policy research, polling and journalism organization who has no relation to Stacy Cox. 

Today, about half of all adults enrolled in the ACA are small business owners, work for a small business or are self-employed, according to a KFF analysis. Roughly five million small business owners and self-employed workers were likely to be enrolled in the ACA at some point last year — and enhanced tax credits saved enrollees an average of $705 annually.

Women-owned businesses represent nearly 40 percent of all U.S. businesses. But while they employ more than 12 million workers, the bulk of these businesses — about 90 percent — have no employees, according to federal data.

From 2019 to 2023, women-owned businesses were outpacing the growth rate for men on every front, including new business creation. Survey data from 2022 showed women created about half of all new businesses — a jump from the 29 percent they represented before the pandemic.

Cox, who said she has had a camera in her hand since she was in grade school, didn’t immediately think of photography as a way to make a living. She has degrees in accounting and public service and worked for years as an auditor. In 2013, Cox began photographing as a side gig — taking occasional photos of friends for special occasions and building a client roster bit by bit. At the end of 2021, she quit her job at a medical device company to be a photographer full time.

Cox said the ACA made her entrepreneurial dreams a reality. Knowing that she would have guaranteed health insurance that was comprehensive and affordable was a critical step as she considered what it would take to branch out on her own. 

“It was the last piece that I needed. I had the knowledge, had the motivation. I had been saving money so that I had a foundation to be able to leave my current employment to do this, but none of that would have even mattered,” she said. “It all hinged on: Can I get health insurance?”

Starting her business, Cox said, has been amazing. She has built a following in her town of 5,000 people. She takes photos of her neighbors, everything from maternity shoots to newborn sessions to annual family photos. She loves selling landscape prints of Utah’s scenery. She’s also expanded her skills by photographing properties for real estate agents.

It’s been fulfilling and empowering work, on her own terms — and it all feels really fragile right now.

“I want people to know that this is primarily going to impact people like us — working individuals and small businesses. That is who this is going to hurt the most,” she said. “It matters having this program available. Having affordable health insurance matters.”

These are among the impossible options millions of people across the country face, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at the Georgetown University McCourt School of Public Policy.

“They either have to make pretty significant sacrifices in their budgets to afford what is for many a doubling or even tripling of their premium to maintain their health insurance coverage — and the financial protection that it provides if they get sick or injured — or they have to roll the dice and go uninsured, which exposes them to potential financial catastrophe if they get sick or injured,” she said.

Cox and her husband are considering whether to enroll in short-term health insurance — a kind of temporary medical coverage that is often cheaper than more traditional insurance — but such programs don’t often cover preexisting conditions and often include high deductibles. Women disproportionately have preexisting conditions — including pregnancy and certain types of cancer — that would have left them uninsurable in a pre-ACA individual marketplace.

“It’s really just if you get shot or run over, and the premiums aren’t that great. I think the lowest one we found is just shy of $700 a month,” she said. “It’s disconcerting. I’m just really angry, and on the other hand, I’m really scared.”

Laura Packard is a self-employed digital content creator and stage 4 cancer survivor in Virginia who advocates for affordable health care. She also has an ACA plan and saw her premiums increase by more than 20 percent for the current enrollment year.

Packard said before she was enrolled in the ACA, she was part of a short-term health plan with limited coverage. At the time, she was relatively healthy — her Hodgkin’s Lymphoma diagnosis came in 2017, while she was already an ACA enrollee.

Packard feels fortunate that her diagnosis happened while she was no longer part of a short-term plan.

“​​I could have been bankrupt or dead. And that’s the danger with these short-term plans,” she said. “They take your money, but they don’t actually provide the high-cost care that you might need, just when you need it most.”

On Thursday, amid the final hours of the enrollment deadline, Cox said she and John had decided to go with a short-term plan.

“We can’t afford a catastrophe that could impact our financial future through our credit for years to come,” she said.

Cynthia Cox with KFF noted that some small business owners with flexible incomes — meaning that they have say over how much they make in a year — might consider working less to qualify for some tax credits that are still available for some poorer enrollees. Or they may contribute more to a retirement account to lower the part of their income that is counted for subsidy eligibility.

Packard encouraged some people who were enrolled in the ACA to let their policies auto renew, since there is typically a grace period for some coverage until the policy is terminated. She noted that there are federally qualified health centers in many places that offer sliding scale medical treatments, as well as some free medical clinics.

“These are not solutions for a broken health system,” she said. “But for one individual, maybe it’ll help a little bit around the edges.”

Cox said she and John considered letting their ACA plan auto-renew, but it ultimately did not make sense for them.

“We realized that I don’t want to pay $2,168 for a month of coverage when we’re not going to be able to maintain that. So why give up the extra $1,500 this month?” she said. “This would be different if we were jumping from $500 to say, $900 a month or something, that’d be a totally different conversation.”

Cox, who identifies as an independent, voted for Democrat Kamala Harris in the 2024 election. But she doesn’t view this issue through the lens of politics. She said the health of a community relies on preventative care.

“It’s a giant connected circle. People that have health insurance will actually go to the doctor,” she said. “If they don’t have health insurance, they won’t go. It means that many people in the population won’t be as healthy as they could be. This is your neighbor. This is your church member. This is your dog walker. This is your realtor. All these people that are like us — the individuals and small business owners — won’t be as healthy. That affects your community.”