Pennsylvania farmers face rising health care costs as ACA subsidies expire

By Rebekah Alvey for Civil Eats.

Farming is a profession full of risks. It is physically strenuous and often involves dangerous heavy machinery. Accident reports include farmers falling into grain bins, trapped by farm machinery, shocked by equipment, and more. Farmworkers are also more exposed to chemicals, dust, and gases.

Then there’s the mental toll as farmers navigate challenges outside their control, from financial markets to natural disasters. Suicide rates among farmers are two to five times higher than the national average, according to the American Farm Bureau.

At the same time, most farmers have limited access to health care because of the high costs of being self-employed.

Over the years, tax credits and other subsidies included in the Affordable Care Act have helped lower premiums and made it easier for farmers to access reliable care. Now, though, farmers across the country are bracing for new difficulties ahead. That’s because tax credits created under the Biden administration are set to expire at the end of the year; without congressional intervention, that will mean, on average, a doubling of premiums. At the start of November, farmers on ACA-subsidized plans began getting notices that premiums are increasing.

Those higher premiums will come at a time when farmers can least afford them: Tariffs, federal funding freezes, and extreme weather are making farming more expensive, with margins tighter than ever. And the loss of credits isn’t just a threat to individuals: It will also impact entire communities across farm country.

“That’s just not sustainable, because right now the margins aren’t there for farming at all,” said Gary Wertish, president of the Minnesota Farmers Union.

Taken together, this has left farmers across the country with a number of bad options: pay premiums at the expense of operations; take only catastrophic policies; drop insurance completely; or move somewhere cheaper.

How the Affordable Care Act Impacts Farmers

The ACA was signed into law in 2010 by then-President Barack Obama. Among other major reforms to U.S. health care, the ACA established new policies and protections for private insurance purchased from the marketplace. Later, the Biden administration implemented ACA-enhanced premium tax credits that limited the amount a person must pay for upfront costs of insurance.

These enhanced credits were extended by the Inflation Reduction Act through 2025. If they are not extended, the original ACA premium caps will return, and that is expected to raise premiums.

Florence Becot, a researcher with Penn State University, has focused on farmer access to services like health care, child care, and mental health services for the past decade. She said access to affordable health care has been a persistent issue year over year.

When the ACA was first adopted, Becot said, farmers were split on the package. For some it was life-changing, while others lost access to coverage plans they’d had for years. But more recently, with the passage of the credits and other additions to the ACA, the cost for plans has dropped.

Getting insurance from the ACA marketplace has often been the last resort for many farmers, she said, but many have found it easier because of the ACA credits.

Now approximately 27% of farmers rely on health care from the marketplace, which is about triple the national average for the rest of the population, according to a Kaiser Family Foundation analysis of the 2023 American Community Survey. This also represents a nearly 10% increase among farm households that relied on private direct-purchase insurance in 2015, according to data from the U.S. Department of Agriculture.

The bulk of farmers are buying their own health care because they are not under a group plan from a large employer. The out-of-pocket premium payment for ACA marketplace enrollees across income levels was an annual average of $888 in 2025, but that is expected to increase to $1,904 in 2026, according to a Kaiser Family Foundation study.

The costs are amplified in states with above-average health care premiums. If the ACA credits expire, Vermont residents using marketplace insurance and making about $63,000 in annual income could see premiums increase to $10,000 per year for an individual and $32,000 for a family of four, according to Public Assets Institute.

“It’s pretty much going to be out of reach for many of them,” said Graham Unangst-Rufenacht, policy director at Rural Vermont.

In 2025, over 30,000 Vermont residents who received these enhanced credits saved an average of $946 per month on their premiums. Unangst-Rufenacht said these subsidies have become one of the only ways that thousands of farmers and small-business owners are able to afford health insurance.

The expiration of insurance subsidies could hit dairy farmers the hardest. Uninsured rates among this group are significantly higher than in other types of farming operations.

According to a 2015 USDA study, 41% of dairy farmers were uninsured, compared to 10.7% of all farm households. This is because their work requires milking cows multiple times a day, which makes it challenging to have an off-farm job to supplement income or get access to employer-backed insurance. Dairy products also have tighter profit margins, which could explain the large divide in uninsured rates.

And now that these credits could be expiring, farmers across the spectrum are weighing difficult decisions and less-than-ideal alternatives.

Difficult Choices Ahead

Some farmers could opt to stay on their current plans and absorb the increased premium cost. But this could tighten already thin margins within their operation.

“Farming can be an incredibly taxing job, physically, emotionally, mentally,” said Maddie Kempner, policy and organizing director at the Northeast Organic Farming Association of Vermont. “So, having high quality and affordable health care is really critical to farmers and people who work on farms.”

The farming community has been anticipating the blowback from these credits expiring since at least June, Kempner said. Some farmers are considering purchasing high-deductible catastrophic policies. These plans have lower monthly premiums, but participants must pay for care until the higher deductible is met. These are largely beneficial to have in place in case of serious illness or injury, not necessarily preventative care.

Some farmers, like those living in states with abnormally high health care costs, are considering moving, Unangst-Rufenacht said.

Other farmers access health care through an off-farm job like teaching or construction. Becot found that about 60% of farmers have one of these jobs, though most would rather focus on farming full time.

“We’ve heard a lot about how the way the health insurance system kind of holds back people from focusing on their businesses . . . and how that adds layers of stress as people have to manage a lot of demands,” Becot said.

With the credits potentially expiring, more farmers may consider taking up off-farm jobs to maintain insurance.

Farmers with inadequate coverage could split up pills or take partial doses of medication to expand the length of a prescription, or delay surgeries until they qualify for Medicare, Becot said. This all impacts their quality of life and ability to farm. It also means that the long-term cost of treating an illness or injury could be more expensive down the line, since the condition will likely have worsened, Becot continued.

“We often hear that farmers are a tough crowd, [that] they don’t want to go to the doctor,” Becot said. “The story that I’ve heard is, ‘It’s not that I don’t want to go to the doctor, but it’s not affordable, my health insurance won’t cover it, or there isn’t a doctor available in my area.’”

Some are even weighing going without insurance entirely. Farmers looking at an uncertain economic future may not know if they’ll have funds for care, Wertish said. “It’s going to have a huge ripple effect.”

How Farm Communities Will Feel the Effects

If a big chunk of a community drops out of the health insurance marketplace, hospital incomes will also be impacted. This will most affect rural hospitals that are already facing economic pressure and cuts from Congress.

Nationally, about 190 rural hospitals have closed or ended inpatient services since 2010, according to the National Rural Health Association. This year alone, another 432 rural hospitals have been marked as vulnerable to closure, Carrie Cochran-McClain, chief policy officer at NRHA, told Civil Eats. That’s based on factors like negative operating margins, cash on hand, and other indicators of long-term financial health.

The Republicans’ One Big Beautiful Bill included changes to Medicaid that are also expected to have a significant impact on rural hospitals. On average, these hospitals are projected to lose about 20% of their Medicaid budget due to policy changes — including, for example, shifts in how a state pays for its Medicaid program, Cochran-McClain said.

The expiration of the ACA enhanced premium tax credits are expected to intensify all these issues for rural hospitals. Cochran-McClain said rural areas are more reliant on the subsidies. If farmers or others living in these areas drop their ACA marketplace coverage, this could push up overall insurance costs for everyone else in their community with ACA coverage.

For everyone remaining in the marketplace, premiums, co-pays, or deductibles are likely to rise, Cochran-McClain said.

If farmers opt for catastrophic plans, they will be more likely to seek care when it’s more urgent and when they are sicker. This means it will cost rural hospitals more to treat patients as well, Cochran-McClain said.

Without an extension of subsidies and given other economic pressures, rural hospitals may reconsider what services to provide or what investments to make in their facilities. It could also drive up health care prices across the community.

“There’s a real rippling effect there,” Cochran-McClain said. “It’s better for everybody involved if you can get as many folks as possible covered in an adequate manner.”

An Unclear Path to ACA Extensions

The ACA credits were the main reason Senate Democrats held out through the government shutdown, the longest in history. Democrats wanted an extension of enhanced premium credits under the ACA.

However, as the shutdown dragged on, a handful of Senate Democrats joined Republicans to reopen the government — leaving this key demand unmet. As part of the deal to move ahead, though, Senate Republican leadership promised a vote on the ACA credits.

There is no guarantee that this vote will pass the Senate, however. And House Speaker Mike Johnson (R-LA) has refused to commit to even holding a vote, even though some Republicans, including Representative Marjorie Taylor Greene (R-GA) and more centrist members, have raised concerns about the potential impact of the credits expiring.

That leaves an unclear path ahead.

Any congressional action needs to happen quickly for those relying on the credits. Farmers are already selecting their 2026 health plans. If individuals want coverage starting the first of next year, most will need to make these selections by Dec. 15, though some state-run marketplaces may have different deadlines.

Democrats have introduced legislation to extend the credits for three years, which could provide some certainty and relief for farmers. But right now, the situation remains volatile.

“It’s hard to have a family farm these days on lots and lots of levels,” Cochran-McClain said. “Having to afford your health insurance coverage should not be one of the things that our farm families are struggling with day to day. I am worried that as the potential non-renewal happens here. … It will have this effect that I don’t know that people really, fully understand.”

This story was originally published by Public news Service.