Fact check: Which states will be most impacted by the ACA subsidy expiration?

1. Why these eight states stand out — the numbers behind the headline

Recent modeling released in September 2025 quantifies the potential fallout from ending enhanced premium tax credits: nearly 4.8 million people becoming uninsured and a dramatic drop in subsidized enrollment concentrated in eight states where enrollment would fall by more than 50 percent ^[1]. The models combine current Marketplace enrollment patterns with simulated premium increases and income distributions, producing state-level projections that consistently flag Georgia, Louisiana, Mississippi, Oregon, South Carolina, Tennessee, Texas, and West Virginia as most exposed. These states either had large shares of households whose premiums were kept affordable by enhancements, or they rely on federal Marketplace dynamics that left many enrollees with limited state-level buffers ^[1].

2. State policy choices that amplify or blunt the hit

Independent analyses emphasize that Medicaid expansion and the type of Marketplace (state-run vs. federal) materially affect how subsidy loss translates into uninsurance, with expansion states and state-run Marketplaces generally achieving larger coverage protections historically ^{[2] [3]}. Studies of the COVID-era expansions and enhanced credits show bigger declines in uninsurance where states expanded Medicaid and invested in outreach, while states relying on HealthCare.gov experienced smaller relative gains from earlier reforms and therefore face steeper reversals. That means the same federal policy change will produce uneven state outcomes because of preexisting policy architecture and administrative capacity ^{[2] [3]}.

3. How diminishing affordability drives enrollment collapse

The core mechanism the studies identify is affordability: enhanced credits capped premiums relative to income, preventing premium-driven churn and dropout. When credits expire, premiums for many low- and moderate-income enrollees would rise sharply, pushing some into Medicaid where eligible, but leaving others uninsured because premiums and out-of-pocket costs become unaffordable ^[1]. Broader insurance-coverage research from late 2024 documented high levels of underinsurance and cost-related barriers—23 percent underinsured and 9 percent uninsured—underscoring that out-of-pocket costs and deductibles already impede care, so subsidy removal compounds existing affordability shortfalls ^[4].

4. Evidence from prior subsidy and payment changes offers a mixed precedent

Past policy shifts—like termination of cost-sharing reduction payments—showed consumer plan choices and market dynamics adjust in ways that can harm affordability for low-income enrollees, such as migration toward cheaper bronze plans and away from silver plans that previously housed cost-sharing protections ^[5]. Research on the pandemic-era enhanced credits and continuous Medicaid coverage also found substantial coverage gains, indicating reversals would likely widen coverage gaps, particularly for low-income adults in non-expansion states ^[3]. These historical cases signal that both coverage and plan composition could shift unpredictably if subsidies lapse, with low-income people disproportionately affected ^{[3] [5]}.

5. Who gains and who loses — the demographic and geographic picture

The modeling and coverage surveys together indicate that low- and middle-income adults, particularly in the eight highlighted states, would disproportionately lose subsidized coverage, while some eligible populations might transition into Medicaid where expansion exists; others would face shrinking options and rising costs ^{[1] [4]}. Rural and southern states on the list—Mississippi, Louisiana, West Virginia and parts of Georgia and Tennessee—have higher shares of lower-income residents and often more limited provider networks, meaning insurance loss can translate quickly into reduced access to care. Urban settings like parts of Oregon and Texas also show vulnerability through large Marketplace enrollments concentrated in income bands that benefited most from the enhanced credits ^{[1] [4]}.

6. Alternative viewpoints, political framing, and potential agendas

Stakeholders framing varies: advocacy groups and some researchers emphasize the human toll and push for legislative extension of enhanced credits, citing the 4.8–5 million estimate as a public-health emergency ^[1]. Opponents argue fiscal or market-distortion concerns and point to long-run premium impacts of temporary subsidies. Policy reports and congressional memos in mid-2025 also used large estimates to argue for or against legislative fixes, so readers should note that economic modeling can be used to support divergent policy arguments, and numbers reflect modeling choices about behavioral responses and market dynamics rather than immutable outcomes ^{[6] [1]}.

7. What this means for policymakers and next steps

The evidence indicates that targeted state actions—expanding Medicaid, bolstering outreach, running state Marketplaces, and offering state-level premium assistance—can blunt the worst impacts, while federal legislative choices determine the baseline risk for millions ^{[2] [3]}. Given the concentrated exposure in the eight named states, policymakers there face predictable surges in uninsurance absent intervention; mitigation requires coordination between state programs and potential federal backstops. The models provide actionable intelligence for prioritizing relief, but outcomes will depend on political choices, administrative readiness, and whether Congress or states move to replace or extend current enhancements ^{[1] [3]}.