How many people will lose coverage if the ACA enhanced subsidies are not extended

1. The headline numbers: 2.2 million versus 4.8 million

The CBO’s estimated coverage loss of about 2.2 million people in 2026 is the lower, frequently cited figure and was offered to inform Congressional decision‑making ^[1]; by contrast, the Urban Institute’s projection that 4.8 million people would drop or lose insurance underexpansion expiry is substantially higher and has been used by many outlets and policy analysts ^{[2] [3]}. Both numbers circulate in media and policy commentary, and both have been cited by health systems and state officials assessing potential downstream effects ^{[6] [7]}.

2. Why projections diverge: different models, baselines and behaviors

The divergence reflects model choices: CBO typically models behavioral responses, take‑up, and macroeconomic feedback differently than academic teams, and the Urban Institute analysis uses assumptions about premium increases, price sensitivity, and who will drop coverage that produce a larger uninsured increase ^{[2] [1]}. Some analyses emphasize the number of people who will face higher premiums (about 22 million) rather than those who will definitively drop coverage, and analysts warn that premium shocks can cause both immediate disenrollment and slower erosion of the risk pool that raises costs further ^{[4] [8]}.

3. Who would be hit hardest — and where the pain is concentrated

Both academic and policy reporting indicate the loss of enhanced credits disproportionately affects middle‑income households, older buyers, and people in high‑cost states where premiums spike most, and several states could see subsidized enrollment fall by more than half under the expiration scenario ^{[9] [2] [6]}. Analysts warn rural communities, communities of color, and small‑business owners who rely on the marketplace would be among the most affected groups, and that hospitals and safety‑net providers could face increased uncompensated care burdens ^{[9] [6]}.

4. Premiums vs. losing coverage — the broader market effects

A larger cohort—roughly 22 million people—would experience large premium increases if the enhanced credits lapse, with the average marketplace enrollee seeing premiums rise substantially (KFF’s estimate of a 114% average increase is widely cited) ^{[4] [5]}. Analysts warn those premium shocks can trigger adverse selection — healthier people dropping coverage — which in turn can drive further premium increases and additional coverage losses over time, an effect captured in some models but not identically across all forecasts ^{[9] [8]}.

5. Political timing and partial mitigations matter for final outcomes

Congressional action or state interventions can materially change outcomes: several states have used short‑term funds or regulatory tactics to blunt premium spikes, and the House has moved legislation to extend the subsidies while the Senate’s prospects remain uncertain — all political developments that could reduce the number who ultimately lose coverage ^{[7] [10] [11]}. Coverage projections cited above assume no federal extension; if lawmakers act, either retroactively or prospectively, enrollment and uninsured estimates would change ^{[8] [11]}.

6. Bottom line — the best direct answer from current reporting

Based on the available, contemporaneous analyses, the best direct answer is that estimates range: the CBO projects roughly 2.2 million people would lose insurance in 2026 if enhanced subsidies are not extended ^[1], while Urban Institute researchers project about 4.8 million people would become uninsured under the same assumption ^{[2] [3]}; many more—on the order of 20–22 million—would face large premium increases even if they do not all drop coverage ^{[4] [5]}. Sources differ in methods and assumptions, and political or state actions could alter these outcomes ^{[1] [7]}.