There’s a brightness to Shanice Jordan’s hospital room at UT Southwestern Medical Center in Dallas.
Her father works in the chair next to her bed while she makes progress on a stocking she’s embroidering for her niece. Hospital stays are kind of routine for her — she was diagnosed with lupus in 2003.
“My preexisting conditions are not illnesses caused by anything that I did,” Jordan said. “I didn't ask for lupus.”
Jordan has two types of lupus, a chronic autoimmune disease that causes her immune system to attack healthy parts of her body.
She’s one of more than four million Texans who rely on health insurance through the Affordable Care Act Marketplace. But subsidies that make those health plans more affordable are set to expire at the end of the year — causing premiums to more than double for most ACA enrollees.
That uncertainty has left Jordan and many other Texans making difficult decisions ahead of Monday’s open enrollment deadline for plans that begin on Jan. 1.
“We might have to forego a lot of things," Jordan said, "but at least I have health insurance."
Significance of ACA coverage
Jordan was diagnosed before the ACA passed in 2010.
“I still remember the day [the congressional vote for the ACA] was on TV,” she said. “My dad came and got me, knocked on my door, said ‘Shanice, you have to come and see this.’ And we watched it together.”
Jordan said it was a relief to herself and her parents. There was a small gap between when she lost coverage under her parents’ insurance and when the ACA passed.
“When I did age out…of my father's insurance, he decided to pay insurance through I think a program called COBRA and it became very expensive,” Jordan said. “Even back then he was paying maybe six hundred dollars a month and that just became too much.”
At the time, her lupus was in remission, so they eventually decided to forego insurance while waiting for the ACA. Not long after, a small trip to an urgent care clinic turned into a flare-up. She debated even going to the hospital because she didn’t want to add more stress to her parents.
That visit cost them a lot.
“There was just no way we were going to be able to pay five-digit health care bills in the amount of time that [the hospital] wanted me to pay them back,” Jordan said.
The ACA brought a lot of changes to health care, including the introduction of the federal health insurance marketplace — which made insurance more accessible, especially for people with chronic conditions like Jordan.
Weighing options
Since enrolling, Jordan has been able to build a team of medical providers that help manage her lupus.
Because of that, she’s very intentional about how she chooses her health plan each year.
Her premium is currently $173 dollars a month; it’s partly subsidized by the Enhanced Premium Tax Credits introduced in 2021. But with those set to expire at the end of the year, her premium will increase to $942 a month — more than five times her current premium for the exact same plan.
She’s nervous about how she’s going to manage the monthly amount and how the heavier financial burden will factor into her decisions around care.
“When I start experiencing the pain, do I tell my parents that I'm having this pain? Is this some pain that I can live with?” Jordan said. “From experience I know I shouldn't because there have been times where the people in the ER have said ‘If she would have waited just one more day, she would be dead.’”
She debated moving to a lower cost plan, but was concerned about having access to the providers, medications and services she relies on.
A lot of Texas families are facing similar decisions because of the skyrocketing cost of premiums.
Lynn Cowles, with the advocacy group Every Texan, volunteers as a Certified Application Counselor helping people sign up for insurance.
“There's a lot of hesitance, a lot of confusion, a lot of disappointment, sometimes anger,” she said.
People have to choose between what Cowles calls “two devasting financial situations.”
“Pay $20,000 a year for your health insurance premiums or potentially pay hundreds of thousands of dollars per year if you have somebody in your family who ends up needing some major medical care,” Cowles said. “That's the position that the government is putting people in right now.”
Cowles said some people are discovering they can no longer afford even the least expensive plan available.
“Some of those families are making really difficult decisions about which family members to insure,” Cowles said.
“So you have mixed insurance status households where some people have health insurance and some people don't. People are making the really difficult decision to go uninsured.”
Texas already has the highest uninsured rate in the country — and experts and advocates expect it to get even worse once the enhanced tax credit expires.
Rising costs
Blake Hudson, with the Texas Association of Health Plans, said there’s been a lot of growth in ACA enrollment over the last several years — from 1.1 million in 2020 to about four million in 2025. He’s worried the loss of enhanced premium tax credits will send the state backwards in helping connect people to coverage and care.
“There's a big chunk of Texans that won't get any help at all anymore, or the amount of help they get will be severely cut,” Hudson said.
He said rising premiums and people choosing to go uninsured will affect health insurance costs for everyone.
Health plans need a mix of “high users” and “low users” to have a market that works well. But when health insurance becomes unaffordable, Hudson said younger and healthier people that make up the “low user” group are more likely to go without it.
“You get left with a pool of people that are covered that are older or sicker and have higher healthcare costs and needs,” Hudson said. “Ultimately, that increases the cost of health insurance.”
As more people become uninsured, that can also increase the pressure on emergency rooms and providers — which can also lead to increasing costs and even loss of services.
“Research after research shows that when you have health insurance, you get preventive care earlier,” Hudson said. “That's foundational to the way all this works.”
Even in the most basic plans, certain services are fully covered by insurance companies. And if someone decides to go without health insurance, navigators like Cowles connect people with community health clinics, which accept people regardless of their ability to pay.
While there are some resources available for people without insurance to get preventive care, Cowles said that doesn’t always mean the problem is solved. Even if preventive care catches something early, that doesn’t address the need for follow-up.
“At some point some people just say, ‘Oh, well, why would I go get preventive care if I can't afford health care after that?’” Cowles said. “We're really seeing some large scale feelings of betrayal I think in the buyer health care system.”
Uncertainty going into 2026
At UT Southwestern, Shanice Jordan sat in her hospital bed explaining the challenges she’s had to navigate to maintain her health in between sharing photos and explaining how she decides what crafts she wants to pick up.
But the fate of her health coverage isn’t exactly in her hands — or even the hands of her family who have acted as a support system for her for more than two decades. As the Dec. 15 open enrollment deadline approaches, federal lawmakers are still considering last-minute deals to extend the tax credits.
Jordan said she’s hopeful lawmakers will do the “right thing.”
For now, she has to plan like her premium will be more than $900 a month. She’s spent the past few months working with her doctors to make sure everything is in order ahead of Jan. 1, but she said there’s only so much planning she can do.
“All those January appointments I get so nervous about because it's January,” Jordan said. “I don't know how it's going to look this time.”
She said many people, including federal lawmakers, don’t understand the importance and significance of the ACA.
“It's not people that are just full of preexisting conditions,” she said. “These are people that are fighting for the American dream, trying to have their own business. ... They're not thinking about the people [this] is truly affecting.”
Abigail Ruhman is KERA’s health reporter. Got a tip? Email Abigail at aruhman@kera.org.
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