For Mikayla Tencer, being self-employed already meant juggling higher taxes, irregular income and the constant pressure of finding her own health insurance. This year, it also meant rethinking how often she could afford to see a doctor.

The 29-year-old content creator in San Francisco paid $168 a month last year for a Blue Shield health plan through Covered California. This year — without enhanced federal subsidies that expired at the end of December — that same plan would have cost $299 a month, with higher copays.

“People assume that because I’m young, I can just pick the cheapest plan and not worry about it,” Tencer said. “But I do need regular care, especially for mental health.”

Tencer is among tens of thousands of middle-class Californians facing steep increases in health insurance costs after Congress allowed enhanced federal subsidies for Affordable Care Act plans to expire Dec. 31.

Those extra subsidies were enacted in 2021 as part of temporary, pandemic-era relief, boosting financial help for people buying coverage on state-run insurance marketplaces such as Covered California. The law also expanded eligibility to people earning more than 400% of the federal poverty level, about $62,600 for a single person and $128,600 for a family of four.

With the expiration of the enhanced subsidies, people above that income threshold no longer receive federal assistance, and many who still qualify are seeing sharply higher premiums and out-of-pocket costs. On top of the loss of the extra federal benefits, the average Covered California premium this year rose by 10.3% because of fast-rising medical costs.

Jessica Altman, executive director of Covered California, said that about 160,000 Californians lost their subsidies when the enhanced federal assistance expired because their incomes were higher than 400% of the federal poverty level.

To lower her monthly bill, Tencer switched to the cheapest Covered California option, bringing her premium down to about $161 a month. But the savings came with new costs. Primary care and mental health visits now carry $60 copays, up from $35.

When she showed up for a psychiatric appointment to manage her ADHD and generalized anxiety disorder, she said, she learned her doctor was out of network.

“That visit would have been $35 before,” she said. “Now it’s $180 out of pocket.”

Because of the higher costs, Tencer said she has cut therapy from weekly to biweekly sessions.

“The subsidies made it possible for me to be self-employed in the first place,” Tencer said. “Without them, I’m seriously thinking about applying for full-time jobs, even though the market is terrible.”

For another self-employed Californian, the increase was even more dramatic.

Krista, a 42-year-old photographer and videographer in Santa Cruz County, relies on costly monthly intravenous treatments for a rare blood disorder. She asked that her full name not be used but shared her insurance and medical documents with The Times.

Last year, she paid about $285 a month for a Covered California plan. In late December, she received a notice showing her premium would rise to more than $1,200 a month. The rise was due to her loss of federal subsidies, as well as a 23% increase in the premium charged by Blue Shield.

“It terrified me. I thought, how am I ever going to retire?” she asked. “What’s the point?”

Krista ultimately enrolled in a plan costing about $522 a month, still nearly double what she had been paying, with a $5,000 deductible. She said she cannot downgrade to a cheaper plan because her clinic bills her treatment to insurance at roughly $30,000 a month, according to medical statements.

To cut costs and preserve the ability to save for retirement and eventually afford a place of her own, Krista decided to move into an RV on private land. The decision came the same week she received notices showing a rent increase and a steep jump in her health insurance premiums.

Mikayla Tencer, a marketing influencer, with her elder dog, “Lucky” at Alamo Square Park.

(Paul Kuroda/For The Times)

Krista said she had been planning for more than a year to find a long-term living situation that would enable her to live independently, rather than continue paying more for an apartment.

“Nobody asks to be sick,” Krista said. “No one should have their life ruined because they get diagnosed with a disease or break a leg.”

Although overall enrollment in Covered California this year has held steady, Altman said, she worries that more people will drop coverage as bills with the higher premiums arrive in the mail.

Those fears are already playing out.

Jayme Wernicke, a 34-year-old receptionist and single mother in Chico who earns about $49,000 a year, said she was transferred from Medi-Cal to a Covered California Anthem Blue Cross plan at the end of 2023. Her premium rose from about $30 a month to $60, then jumped to roughly $230 after the subsidies expired.

“For them to raise my health insurance almost 400% is just insane to me,” Wernicke said.

Her employer, a small family-owned business, does not offer health insurance. Her plan does not include dental or vision care and, she said, barely covers medical costs.

“At a certain point, it just feels completely counterintuitive,” she said. “Either way, I’m losing.”

Wernicke dropped her own coverage and plans to pay for care with cash, calculating that the state tax penalty is less than the cost of premiums. Her daughter remains insured.

Two other Californian residents told The Times that they also decided to go without coverage because they could no longer afford it. They declined to provide their full names, citing concerns about financial and professional consequences.

Under California law, residents without coverage face an annual penalty of at least $900 per adult and $450 per child.

One, a 29-year-old self-employed publicist in Los Angeles requires medication for epilepsy. Last year, she paid about $535 a month for a silver plan through Covered California. This year, the same plan would have cost $823.

After earning about $55,000 last year, she calculated that paying for care out of pocket would cost far less. Her epilepsy medication costs about $175 every three months without insurance, and her annual doctor visits total roughly $250.

“All of that combined is still far less than paying hundreds of dollars every month,” she said.

Another, April, a 58-year-old small-business owner in San Francisco, canceled her insurance in December after her quoted premium rose to $1,151 a month for a bronze plan and $1,723 for a silver plan, just for herself. Last year, April said she paid $566 for both her and her daughter. This year, her daughter’s premium alone jumped from $155 to $424.

The bronze plan also carried a $3,500 deductible for lab work and specialist visits, meaning she would have had to pay thousands of dollars out of pocket before coverage kicked in, on top of the higher monthly premium.

“The subsidies were absolutely what allowed me to sustain my business,” April said. “They were helping me sustain my financial world and have affordable care.”

She rushed to complete medical tests before dropping coverage and hopes to go a year uninsured.

“The scariest part is not having catastrophic coverage,” she said. “If something happens, it can be millions of dollars.”

Tencer, the content creator in San Francisco, believes that in order to make the nation healthier, affordable healthcare should be universal.

“Our government should be providing it.” she said. “People can’t go to the doctor for routine checkups, they can’t get things checked out early, and they can’t access the resources they need.”