How would ending the enhanced ACA premium tax credits after 2025 affect Marketplace enrollment and the uninsured rate?
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Executive summary
Allowing the enhanced ACA premium tax credits to lapse at the end of 2025 would sharply raise net premiums for Marketplace enrollees and, according to multiple respected analyses, cause a substantial fall in Marketplace enrollment and a meaningful rise in the uninsured population — with estimates of enrollment loss and new uninsured differing by model but consistently large (CBO, Urban Institute, KFF, Commonwealth Fund) [1] [2] [3] [4].
1. What “ending the enhanced credits” actually does to premiums and eligibility
The enhanced premium tax credits — expanded under ARPA and extended through 2025 by the IRA — both increased subsidy amounts and removed the 400%-of-FPL cliff, so letting them expire would make consumers responsible for a much larger share of premiums and restore tighter eligibility rules; KFF projects average enrollee premium payments would more than double in 2026 if the enhancements are not extended, and CBPP and others describe widespread sharp premium increases for many households [1] [5] [6].
2. How big the Marketplace enrollment decline is likely to be (range and reasons)
Estimates vary by model and assumptions, but the Congressional Budget Office projected a Marketplace enrollment drop of roughly 3.9 million (from about 22.8 million to 18.9 million) in the first year after expiration, while Urban Institute and Commonwealth Fund-based modeling estimate far larger disruptions — Urban projects about 7.3 million people losing ACA coverage in 2026 (with some shifting to other coverage) and the Commonwealth Fund highlights several-million-person drops in enrollment depending on spillover effects — reflecting both price-driven departures and eligibility changes [7] [3] [4].
3. How many would become uninsured — and why estimates differ
Models consistently find millions would become uninsured, but the scale depends on assumptions about who shifts to employer coverage, Medicaid, or becomes uninsured: Urban Institute projects 4.8 million people would become uninsured in 2026 if enhanced credits expire, while other analyses and CBO inputs show somewhat smaller but still substantial increases in the uninsured; differences hinge on local markets, availability of other coverage, and behavioral responses [3] [2] [7].
4. Who would be hit hardest and the market feedback loop
The burden would fall unevenly: people above 400% of poverty would lose assistance entirely, many near that threshold and older pre‑Medicare adults would face the steepest premium jumps, and rural and high-premium areas would be disproportionately affected; analysts also warn of a feedback loop — healthier enrollees would be likelier to drop coverage, worsening the risk pool and pushing gross premiums higher (CBO, Bipartisan Policy Center, Medicare Rights Center, Peterson‑KFF) [8] [9] [10] [2].
5. Broader economic and secondary impacts
Beyond coverage counts, researchers flag spillovers to labor markets and state budgets: the Commonwealth Fund and related modeling estimate significant numbers of people shifting into uninsured status and even job impacts tied to health‑cost shocks, while insurers have already filed 2026 rates that in some states assume the expiration will alter risk mixes and raise gross premiums [4] [10].
6. Key uncertainties, caveats and political levers
All projections rest on behavioral and modeling assumptions — e.g., how many people will move to employer plans or Medicaid, how insurers set rates assuming a sicker pool, and how quickly Congress might act — and agencies note that later legislative action would mitigate but not instantly reverse market frictions (KFF, CBO, CBPP); legal and regulatory changes also interact with outcomes, so the final coverage and uninsured effects depend heavily on near‑term policy choices and insurer reactions [1] [2] [6] [8].
Bottom line
Permitting the enhanced premium tax credits to end would very likely cause large premium increases for Marketplace enrollees, drive a multi‑million reduction in Marketplace enrollment, and raise the uninsured rate by millions — with published estimates clustering from roughly 3.9 million to 7+ million people losing Marketplace coverage and about 4–5 million becoming uninsured in the first year under several major analyses, while recognizing important uncertainty and variation across states and models [7] [3] [4] [11].