What women business owners are poised to lose with health insurance cuts
Stacy Cox has always prioritized having access to health insurance. For the 48-year-old self-employed photographer in southern Utah, it’s necessary “so that I can help to calm my anxiety and know that if I need care, I can get care.” Still, Cox and her husband, John, have decided this month to go uninsured after the cost of their health plan under the Affordable Care Act skyrocketed. At the end of 2025, Congress let enhanced premium tax credits that had helped bring down the cost of the couple’s ACA coverage expire. They were quoted $2,168.68 a month for the same plan that had previously cost them just under $500 a month. It was a “nerve wracking” decision, Cox said. Health insurance has helped keep the couple’s preexisting conditions under control. Cox has an autoimmune disease that requires prescription medication and extra medical care. She is also at a high risk for breast cancer and uses preventative services like more frequent mammograms. John, 55, had a quadruple bypass surgery in his late 30s that has required daily prescription medication. He also has annual check-ins with a cardiologist. “For the most part, we’re healthy middle-aged people, but we’re also middle-aged, which means that every time we wake up, something else hurts or something stops working,” she said. The enhanced subsidies, which were approved in 2021 at the height of the pandemic and later extended, were aimed at making ACA coverage more affordable to a larger group of people. They helped ACA sign-ups soar, with open enrollment roughly doubling since then. Cox had held out some hope that this current iteration of Congress would have taken some action by Thursday — the deadline in most states for people to enroll or renew ACA plans — to keep the enhanced tax credits. That did not happen. While the House passed a three-year subsidy extension on January 8 with the support of all Democrats and 17 Republicans, GOP lawmakers who control the Senate immediately shot down talk of approving the measure. President Donald Trump, who released a health care plan on Thursday with vague details to lower ACA premiums, also told reporters that he might veto the bill if it reaches his desk. Preliminary data on ACA enrollment shows 22.8 million people have signed up for 2026 coverage so far — about 800,000 fewer people compared to this time last year. Experts say it could take months of emerging data to see the full scope of impact. Cox has been self-employed since 2022, and losing her health insurance coverage raises a lot of logistical questions about what comes next. Will she eventually close her small photography business to find an employer that offers private health insurance? Would she have time for photography, even as a side gig? Could such a career pivot force the couple — her husband is also self-employed — to move out of Utah to find more job options? “I don’t want our lives to drastically change because of this,” she said. “That’s what I’m afraid of.” Women like Cox stand to lose major professional gains amid the cuts to ACA. Prior to the enactment of the health law in 2010, many Americans were caught in “job lock” — stuck in careers and workplaces primarily because they offered private health insurance, which people with preexisting conditions often couldn’t access otherwise. This was particularly tricky for small businesses and self-employed people who needed to purchase health insurance on their own. The ACA changed that: By 2022, small business owners and self-employed people represented 18 percent of marketplace coverage for workers between the ages of 21 and 64, according to a 2024 federal analysis. “The Affordable Care Act has given a number of small business owners or self-employed people or gig workers a kind of flexibility to be able to have that type of income,” said Cynthia Cox, a vice president at KFF, a nonprofit health policy research, polling and journalism organization who has no relation to Stacy Cox. Today, about half of all adults enrolled in the ACA are small business owners, work for a small business or are self-employed, according to a KFF analysis. Roughly five million small business owners and self-employed workers were likely to be enrolled in the ACA at some point last year — and enhanced tax credits saved enrollees an average of $705 annually. Women-owned businesses represent nearly 40 percent of all U.S. businesses. But while they employ more than 12 million workers, the bulk of these businesses — about 90 percent — have no employees, according to federal data. From 2019 to 2023, women-owned businesses were outpacing the growth rate for men on every front, including new business creation. Survey data from 2022 showed women created about half of all new businesses — a jump from the 29 percent they represented before the pandemic. Cox, who said she has had a camera in her hand since she was in grade school, didn’t immediately think of photography as a way to make a living. She has degrees in accounting and public service and worked for years as an auditor. In 2013, Cox began photographing as a side gig — taking occasional photos of friends for special occasions and building a client roster bit by bit. At the end of 2021, she quit her job at a medical device company to be a photographer full time. Stacy Cox has been self-employed as a photographer since 2022, and losing her health insurance coverage raises a lot of difficult questions. (Courtesy Stacy Cox) Cox said the ACA made her entrepreneurial dreams a reality. Knowing that she would have guaranteed health insurance that was comprehensive and affordable was a critical step as she considered what it would take to branch out on her own. “It was the last piece that I needed. I had the knowledge, had the motivation. I had been saving money so that I had a foundation to be able to leave my current employment to do this, but