Fact check: What happens to health insurance premiums if the ACA is repealed?

1. Why dollars jump when subsidies disappear — a simple calculus that hits low-income people hardest

Eliminating the ACA’s premium tax credits or letting enhanced credits expire sharply increases the net premiums paid by subsidized enrollees because tax credits directly lower out-of-pocket premium costs; a September 2025 analysis projects average net premiums would be more than four times larger for Marketplace enrollees with incomes under 250% of the federal poverty level if enhanced tax credits expire, illustrating how subsidy design drives affordability ^[1]. That study ties affordability directly to enrollment: when subsidies shrink, many people drop coverage, leaving a smaller, sicker pool that can push insurers to raise gross premiums further. Policymakers proposing repeal would therefore face the twin effects of immediate out-of-pocket increases for subsidy recipients and second-order market responses that further elevate premiums for unsubsidized and future customers.

2. Repeal versus narrow changes — mandate removal tells a different story

Evidence from the ACA’s partial rollbacks shows which levers matter most: repealing the individual mandate penalty in 2019 produced modest premium effects but caused enrollment declines and higher uninsured rates, suggesting mandates influence participation more than pricing directly ^[3]. Analyses of state experiences and academic studies find that removing the mandate reduces the number of healthy people buying coverage, worsening risk pools and nudging premiums upward, but not to the same degree as cutting subsidies. This distinction matters: a full repeal that strips both subsidies and consumer protections will amplify premium increases far beyond those observed after the mandate penalty was removed ^[2].

3. How coverage losses amplify premium pressures — the feedback loop insurers dread

Models of ACA repeal show large coverage losses that feed back into higher premiums; CBO-style projections and academic estimates commonly forecast tens of millions becoming uninsured under comprehensive repeal scenarios, which reduces the size and health of risk pools and drives insurers to raise rates to cover higher average costs ^{[4] [2]}. The September 2025 subsidy-expiration projection highlights this mechanism at a smaller scale: subsidy removal causes enrollment to fall and remaining enrollees to face higher net premiums, which further depresses participation. Insurer pricing anticipates these shifts, so market-wide premium increases can occur even for people who would not lose subsidies, tightening affordability across the board and increasing uncompensated care burdens on hospitals and state budgets.

4. Contrasting projections and why estimates vary — assumptions, timing, and replacement policy matter

Studies diverge because assumptions about behavioral responses, baseline subsidies, and whether replacement policies exist drive different outcomes, making headline numbers sensitive to scenario design ^{[2] [5]}. A model that assumes immediate elimination of premium tax credits and protections will show large premium hikes and big coverage losses, while studies focused only on mandate repeal show smaller price effects but still notable coverage declines ^[3]. Budgetary analyses add another layer: federal deficit and economic context shape the capacity to fund transitions or subsidies, and projections from the Congressional Budget Office stress macroeconomic interactions that can influence health spending trajectories even if they do not parse premium impacts in isolation ^[5].

5. Political choices and alternatives — what policymakers can do to blunt premium spikes

Policy options determine whether repeal leads to chaos or manageable change: maintaining or replacing subsidies, preserving community rating and essential benefits, or creating a different universal system each produces distinct premium trajectories, with single-payer or broad public programs projected to lower national health spending in some analyses while transforming premium structures entirely ^[6]. The September 2025 analysis on enhanced credits shows that targeted subsidy extensions can prevent sharp premium increases for low-income enrollees, whereas full repeal without replacement typically leads to both higher premiums and much larger uninsured populations ^{[1] [4]}. Thus, the practical impact on premiums depends on the legislative trade-offs and transition plans enacted alongside any repeal.

6. Bottom line — repeal raises premiums unless replaced by equal or stronger protections and subsidies

Across multiple studies, the consistent fact is that removing the ACA’s core financial supports raises net premiums for many consumers and destabilizes markets without carefully designed substitutes; partial rollbacks like mandate repeal had smaller price effects but worsened coverage, while elimination of subsidies produces large net-premium increases for low-income people and market-wide upward pressure ^{[1] [2] [3]}. The ultimate magnitude would hinge on which ACA provisions are undone and whether replacements preserve subsidies, protections, and broad participation; absent robust alternatives, repeal results in higher premiums, more uninsured people, and stronger fiscal and system-level stresses documented in recent and earlier analyses ^{[4] [5]}.