Last verified August 2026. This guide is re-checked every September, before open enrollment opens.
What changed in January
The enhanced ACA premium tax credits available 2021–2025 expired on 31 December 2025. Marketplace subsidies reverted to the pre-enhancement structure, which reintroduces the income cliff: above the threshold, you pay the full unsubsidized premium. For a locum physician with variable income, a good year can retroactively cost you the entire subsidy.
For 2026, per KFF and the Center on Budget and Policy Priorities:
- The 400% federal poverty level subsidy cliff has returned.
- Premium payments rose an estimated 114% on average for subsidised enrollees.
- Marketplace enrollment is projected to fall from about 22.3 million in 2025 to roughly 17.5 million in 2026.
The context that matters for this audience: most attending physicians earn above 400% FPL and were never subsidised, so the cliff's return affects them less than it affects most people. What does affect them is that premiums rose across the board as healthier enrollees left the pool.
Two consequences: estimate income deliberately when you enroll, and reconcile at tax time expecting to owe back credits if you undershot.
The one favourable change. As of the 2026 open enrollment period, all bronze and catastrophic plans are HSA-eligible, on- or off-exchange. For a high earner who wants catastrophic cover plus a tax-advantaged account, bronze-plus-HSA is materially stronger than it was. Source: Center on Budget and Policy Priorities.
Legislative status. The House passed a three-year extension of the enhanced credits by 230–196 in January 2026. The Senate outcome is not confirmed in the sources available to us. Verify current status before relying on this.
Six options, ranked for a 1099 physician
- A spouse's employer plan. Almost always the cheapest real coverage. Check whether your locum start creates a qualifying life event.
- Marketplace bronze or silver plus an HSA-qualified plan. Predictable, portable, and the HSA deduction is meaningful at physician marginal rates.
- A professional or specialty association group plan. Worth pricing; quality varies widely by state.
- COBRA from a prior W-2 position. Expensive but seamless, and useful as a short bridge while you shop.
- Health care sharing ministries. Not insurance, no guarantee of payment, no appeals process. Understand that before choosing it.
- Short-term limited duration plans. Last resort. Pre-existing conditions are commonly excluded and they are not ACA-compliant coverage.
HSA arithmetic
If you hold an HSA-qualified plan, fund the HSA fully. The contribution reduces both income tax and, unlike a 401(k) deferral, is available tax-free for medical costs indefinitely. Keep receipts; reimbursement has no deadline.
Do not skip disability
Own-occupation, specialty-specific disability insurance is the coverage a locum physician actually cannot self-insure. Buy it while you are healthy and buy it portable — it is not tied to any agency.
Sources
- KFF — expiry of the enhanced premium tax credits, 2026 premium and enrollment effects.
- Center on Budget and Policy Priorities — return of the 400% FPL cliff, enrollment projections, and HSA eligibility for bronze and catastrophic plans.
- U.S. House roll call, January 2026 — 230–196 vote on a three-year extension.