Higher premiums and penalties have made shopping for Obamacare plans more confusing this year. Navigator programs, a resource for consumers, lost about 90% of federal funding across more than two dozen states earlier this year. How’s open enrollment going so far? “Chaotic,” says one remaining ACA navigator.

For more than a decade, Jeremy Smith has helped West Virginians buy health plans in Affordable Care Act markets. 

Smith works as a navigator, a job created by the ACA to give consumers a guide in the complicated market for insurance. He has traveled the state, walking shoppers through their options. Which plan covers their medication and doctors? Do they qualify for subsidies toward their premiums? Record numbers of people have entered the market in the last few years, keeping him super busy.

This year, he’ll be busy for a very different reason.

Last February, the White House cut federal spending for navigators across more than two dozen states by 90%. Smith still has a job, but First Choice Services, the nonprofit where he works, has closed four of five offices and laid off many of his colleagues.

At first, Smith told Tradeoffs, he was upset. “And then I kind of went into problem solving mode,” he said. “We’re going to throw everything we got at it and see what we can do to still help the people, ’cause we know they need it.”

This year also promises to be extra confusing for shoppers in the ACA markets. Subsidies for premiums are scheduled to shrink in 2026 without action from Congress, which has shut down the government in a standoff over the question. With the smaller subsidies, shoppers will see their monthly insurance bill more than double, on average, an analysis by health policy nonprofit KFF shows.

Enrollment opened this week, and Smith said he’s been talking with consumers who feel pretty overwhelmed – with sticker shock, frustration and indecision. “And, you know, what are they going to do? Go without health care? Or have to pay more and not have enough money for groceries.” 

Here are a few key points from our conversation: 

  • West Virginia consumers’ monthly insurance bills for 2026 on the ACA markets are up by hundreds of dollars, in some cases, Smith said. An analysis by health policy nonprofit KFF shows increases for one plan type in the state runs as high as $2,000 a month, depending on income and age. Some shoppers told Smith they would hold out for Congress to extend subsidies. Others are switching to plans with the cheapest premiums but higher deductibles, Smith said. And a lucky few haven’t seen a huge increase, he said. 
  • Smith’s nightmare scenario is that frustrated shoppers will turn outside the ACA exchanges and end up unwittingly buying a much skimpier plan, such as short-term limited duration coverage, which has fewer consumer protections. Or worse, they could mistakenly buy something that isn’t insurance at all – such as a health-sharing arrangement that pools cash to help cover medical bills, without the benefit guarantees and consumer protections of insurance. “Worst case scenario,” Smith said, “is they get bad advice and they don’t end up getting health insurance.”
  • Smaller subsidies aren’t the only big policy change in ACA markets this year. The Trump administration has expanded access to catastrophic insurance plans (which typically have lower premiums but a very high deductible), as well as access to health savings accounts. Smith said neither provision will likely be of much use to people he helps, many of whom can’t afford the premiums for even catastrophic plans, and don’t have money to sock away in savings. Another change for the coming year: Consumers who incorrectly estimate their 2026 income for subsidies must repay all extra aid in 2027. In prior years, repayment amounts were capped, according to income bracket. Shoppers can update their income as their jobs and work schedules change to avoid facing that subsidy repayment – but Smith fears many won’t. “People are not wired when it comes to health care to think about this,” he said. “They’re used to being one and done.”

We hope you’ll listen or read the full interview to hear more about what Smith loves about West Virginia and what’s at stake as navigators and shoppers react to big policy changes in ACA markets. 

Episode Transcript and Resources

Episode Transcript

Dan Gorenstein (DG): Millions of Obamacare consumers found health insurance more affordable in the last few years, thanks to generous federal aid. 

Now, that help is up in the air.

News clip: Five weeks into the federal shutdown, Congress isn’t any closer to an agreement.

News clip: The sides are entrenched as the shutdown continues.

News clip: The standstill comes down to one key issue.

News clip: As Republicans and Democrats remain deadlocked over expiring health care subsidies under the Affordable Care Act.

DG: Unless Congress takes action, subsidies will drop next year and shoppers will see their monthly bills more than double, on average.

Consumers will now need even more help finding a plan, but there’s less help available. 

In about half of the country, Obamacare navigator programs are federally funded. And the Trump administration has cut that funding by 90%.

Today, we talk with one of West Virginia’s remaining navigators about what’s at stake as consumers shop during this year’s upheaval. 

Jeremy Smith (JS): There’s a lot of paths that somebody can go down that that makes this hard on them and their family, which is why we’re even here in the first place.

From the studio at the Leonard Davis Institute of the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

******

DG: Jeremy Smith is program director for the West Virginia navigator program operated by First Choice Services, a nonprofit based in the state’s capital, Charleston.

 Jeremy, when, when you’re, like, at the family gathering and your great aunt or your great uncle comes up to you and goes Jeremy, what is it you do again? What’s your answer? 

JS:  My family still doesn’t know what I do (laughter).

 It’s complicated. It really is hard to explain what we’re doing. And until somebody has sat down with one of us and we work with them for an hour straight to get ’em through all this, they really don’t exactly know. 

DG: Formally, a navigator is a job created by the ACA to help consumers find a plan. 

Unlike brokers, navigators can’t be paid by insurers.

In his role, Jeremy’s learned the ins and outs of insurance. He’s gotten steeped in marketplace rules. 

He’s also traveled the state promoting coverage at festivals, churches and community centers out in the coal towns of McDowell County – where his grandfather was born and the mountain resorts of Pocahontas County.

JS: I remember driving through there at one point and just kind of pulling off the road and just literally getting out of the car and just looking around and thinking, my God, like, I’ve lived in West Virginia my whole life, but this is blowing my mind.

DG: Now, Jeremy knows buying your own health plan is complicated and deeply personal. 

He spends an hour or more helping someone sort through their health care needs, budget and insurance options. 

JS: I’ve got people that ask for me every year now. And that’s the same way with all my staff too. After they’ve helped somebody, you’re kind of bonded for life.

DG: Jeremy’s been super busy the last few years.

People have flocked to the Obamacare markets after Congress temporarily boosted subsides for consumers to pay for premiums. 

Jeremy and his team have seen a four-fold increase in people who want their help, from about 500 before the larger subsidies to around 2,000 last year.

Normally, in the fall, he’s on the road, getting the word out and signing people up. Some have never had insurance before. 

One woman sticks in his mind. 

JS: Two years ago, a lady came in and she sat down and told a couple of us, she said, y’all may not remember me, but I came in last year and you helped me sign up for health coverage. And little did I know, I had breast cancer. Because after I got my insurance, I went and got checked and they told me if I’d waited any longer, I may not be here. 

And she, she kind of started tearing up and she was just so thankful. She admitted that if she hadn’t have picked up the insurance, she never would’ve went and got the checkup and probably never would’ve found that cancer.

DG: When she started to tear up, did you start to tear up? 

JS: Oh, yeah, everybody did. 

It just kind of reminds you that if people don’t have health coverage, how catastrophic it is. My own parents both benefited at one time or another from either the expanded Medicaid or the marketplace plans.

And, you know, they, they was going through hard times in their life. Cancer diagnosis and job loss and  it makes you feel good that you can be a solution to the problem. That you can help people get where they need to.

DG: Getting people where they need to be is going to be tougher this year, maybe a lot tougher. 

First, Jeremy’s staff is much smaller. The Trump administration cut funding for navigators in the some two dozen states with federally run marketplaces from $100 million down to $10 million.

In West Virginia, Jeremey’s employer First Choice closed four of its five navigator offices. The nonprofit had more than a dozen navigators in the state, but after the cut, only had federal funding for one. 

The White House said navigators enroll too few people to justify all that spending.

So Jeremy, why, in your mind, was this money well spent? 

JS: Well, health insurance programs are so complicated, you almost have to sit down with somebody you can trust in order to understand it and get signed up into the right thing.

Navigators tend to help among the most vulnerable populations in our society. Folks that have a hard time using a computer and can’t do the healthcare.gov website themselves. People that have either low literacy rates in general or just low health insurance literacy.

DG: Jeremy added that money goes for outreach, that’s how people who just lost their jobs, or aged off their parents’ insurance, learned about ACA plans. And, he said, navigators also promote and enroll people in Medicaid and other safety net insurance. 

Jeremy absorbed the blow of the White House funding cuts and started knocking on doors. He ended up raising enough money to hold on to three of his coworkers. 

In late October, a week before open enrollment, I asked him how he felt about his smaller team. 

JS: We’re gonna see what we can do to still give as much help as we can to people, but we know it won’t be of the same caliber or capacity as we’re used to.

I mean, my worst nightmare is we come in and we work all day, and then at the end of the day there’s still 20 voicemails sitting of people that we haven’t been able to get called back.

DG: Jeremy and his condensed team themselves – can only do so much.

So this year they plan to refer people to safety net clinics, called federally qualified health centers, that also help people enroll for coverage. 

And direct folks to a step-by-step guide that First Choice created for anyone who wants to try to do it on their own. 

To maximize their reach, the crew of four do all their navigation by phone this year. 

 Is this the first year that you won’t be going out to Pocahontas? That you won’t be going out to McDowell? 

JS:  Yeah, probably so. We, we’ve gotta do what we can to be as efficient as possible and spend what money we have in the best way to still help as many people. So.

DG: What do you lose by not going to McDowell? I don’t mean you personally, but what in terms of the service. What do the people in McDowell lose because you’re not going to be there?

Um, there’s a lot of people that kind of only trust who they can sit down with and meet face to face. So, we lose that. We lose some of that trust by not being able to go onto their home turf and spend some time meeting them where they’re comfortable. So that that’s a tradeoff. That will hurt some folks. We know it will.

DG: When we come back, open enrollment begins as Congress remains deadlocked on more generous subsidies. We hear from Jeremy about questions and reactions he’s getting as West Virginians start shopping for health insurance. 

BREAK

DG: Welcome back. We are talking with Jeremy Smith, who has helped customers shop for insurance in the Obamacare markets for more than a decade. 

Jeremy has worked for months to prepare for this moment, knowing this year would be tough. 

We caught up with Jeremy at the end of the day after West Virginia’s marketplace had just opened. 

DG: Hey, Jeremy.

JS: Hey, Dan. How are you doing?

DG: How was day one of the new open enrollment season?

JS: Uh, chaotic. And a mix of emotions and frustration. And it was a lot, but it still wasn’t even what I thought it would be, so, I don’t know.

DG: Jeremy told me his day started with black coffee and apprehension. 

DG: He soon jumped in to take some calls and kept an eye on voicemails, to see if his small staff was getting swamped. Around 11, an ACA shopper, one of their regulars, showed up.

JS: He said he didn’t do computers. Didn’t love doing stuff over the phone and he just, you know, he prefers it this way.

DG: This is exactly the consumer that navigators are there to help. 

The man knew the drill, brought his folder with details on his plan and income. Jeremy punched it into the computer. 

Turned out the man’s monthly premiums were only going up $10 bucks. 

JS: He was he was happy. We were pleasantly surprised that he didn’t have a huge premium increase. I mean $10, $20, $50, which is still an increase for people, but it’s not nothing like we thought maybe could happen. 

DG: After that moment of sunshine, Jeremy next spoke by phone with a shopper who learned her plan would go from $200 a month to $800.  

JS: I think that they were completely in shock about the, the possible rate increases. They didn’t know about it. They hadn’t expected it.

So, the good thing about this job is usually everybody’s pretty happy just because you’re giving him so much effort to help them through this complicated process. So. It’s been several years since we’ve had a lot of the consumers that we help kind of get irritated and upset. And, you know, money does that, right? If if you’re having to pay more than you think something’s worth, it’s a justifiable reaction to kind of get curt and upset with somebody even if they’re trying to help you. 

DG: Her cost went up so much, says Jeremy, because the enhanced ACA subsidies – as of January – are going away. 

DG: And when you told her that, what’d she say?

Ah, not a lot. Just okay, let’s do the application. And then when we get to the the end part and start going over the plans, it’s it’s pretty quickly: Well, I, I can’t afford that. We don’t know what we’re doing, and so we’re not showing them the right price. So it was just an initial reaction from them of just being frustrated and just kind of saying, forget it, I’m just going without insurance then and then kind of being like, we’re done here.

DG: We’re done here. Click?

JS: Yeah. Kind of. Like, don’t proceed. We’re done. We can’t afford this. We’re not doing this.

DG: Calls and tough conversations continued as the day went on. 

JS: A lot of those folks were experiencing what we’ve been calling the subsidy cliff.

DG: Right. When the subsidies get smaller next year, some people will no longer be eligible for any aid. These are middle-income households, those who earn more than 400% of the federal poverty level. 

JS: I think one poor person, for a catastrophic plan, was going to be 1500 a month.

DG: A catastrophic plan was going to be $1,500 a month? 

JS: Yeah. 

DG: These are the plans with very high deductibles, right? I think, like, over $10,000 for an individual. More than $20,000 for a family.

JS: Yeah. And so at that point, they were like, nope, sorry, let’s end this conversation. I can’t even come up with that. I’m going to check back in with you in December and see if that’s still the case. 

DG: Actually, a bunch of ACA shoppers told Jeremy and his colleagues they planned to wait, hoping Congress would eventually vote to deliver higher subsidies. 

A little relief at the end of the day, there was no backlog of unanswered calls that Jeremy had feared. But, he almost blames himself for why they only got some 50 calls on day one.

JS: I was scared to death that we wouldn’t be able to meet demand. 

Most years I’m traveling all over the state doing media interviews to promote open enrollment. I didn’t do that this year. I think I maybe talked to one local TV station, whereas normally my October 31st every year is talking to 8 or 10 TV stations across the state; 3 or 4 newspapers; going on radio shows. We’re usually doing paid advertising where, posting on social media and we’re doing videos on social media. So we’re really pushing hard to make sure that the public knows about open enrollment. And we didn’t do that this year. 

I just knew that if I promoted it too hard and we had 50 voicemails sitting there and we couldn’t even call him back, what good does that do either? So, uh, it was a big difference this year, and I feel like we handled the call volume, but it wasn’t nothing like it used to be.

DG: Beyond the smaller subsidies, another change this year, consumers, inadvertently, could end up owing the federal government money.

To get financial assistance, shoppers must estimate next year’s income, but if they underestimate, due to a job change, a bonus, whatever, folks could get an unwelcome surprise at tax time.

Before Republicans passed the Big Beautiful Bill, this so-called ‘clawback’ was capped, that cap is now gone.  

JS: I’m worried about it. People are not wired when it comes to health care to think about this. They’re used to being one and done.

JS: So we’ve added a step in our process that when we sign somebody up, we’re going to email them a form that they will have to click and sign that says that this they agree this is the income they wanted to use and big red letters, it’s ‘s going to remind them about the tax ramifications. And hopefully that will help kind of, make sure that this gets in people’s heads how important this is and how much of a liability this can be if you get it wrong.

DG: When you get to the end of open enrollment this year, what’s your best case scenario? 

JS: I think if we can even help half or three-fourths of the people that we had be helping, I’ll be blown away. 

DG: It is been your job for years to sit across from people where they live and work, hear their stories, help ’em with decisions that could have profound consequences for their health and finances. Thinking about that lady who came back in with the breast cancer. Great example. 

Jeremy, as you think about open enrollment this year, what do the policy changes mean for these people that you have met? 

To me, and understanding how important health coverage is to somebody’s wellbeing, their livelihood, I can’t quite wrap my head around trying to make it harder on people rather than easier. To me, people can’t go without health coverage.

I mean, if you don’t have health coverage in this country, one illness, one surgery, one car wreck can bankrupt you and your family. You have to have health coverage because the cost of getting medical care is just too high without it. So, to me it, it just seems like everybody needs good quality health coverage and why make it harder on people? 

DG: Thanks for taking the time to talk to us on Tradeoffs, Jeremy. Appreciate it. 

JS: Yeah. Thanks for having me.

Episode Resources

Additional Reporting and Resources on Affordable Care Act subsidies and enrollment:

Episode Credits

Guests:

  • Jeremy Smith, director, West Virginia navigator program, First Choice Services.

This episode was produced by Melanie Evans and Dan Gorenstein, edited by Deborah Franklin and Dan Gorenstein, and mixed by Andrew Parrella.

The Tradeoffs theme song was composed by Ty Citerman. Additional music this episode from Blue Dot Sessions and Epidemic Sound.

Special thanks to Sabrina Corlette, Jared Ortaliza and Rhonda Rogombe.

Melanie is a reporter and producer for Tradeoffs. She spent eight years at The Wall Street Journal, where she reported on hospital costs, health care quality and the Covid-19 pandemic. Before the Journal,...

Dan is the Founder and Executive Editor of Tradeoffs, setting the vision for the organization’s journalism and strategy. Before Tradeoffs, he was the senior health care reporter at Marketplace and spent...