Which states or demographic groups stand to lose the most from the 2026 expiration of enhanced ACA tax credits?
Executive summary
The end of the enhanced ACA premium tax credits on December 31, 2025, would sharply raise marketplace premiums and risk large coverage losses: analyses project between about 3.8 million and nearly 5 million people losing insurance in 2026, and average marketplace premium payments would more than double for many enrollees—an average increase of 114% (about $1,016 annually) in one KFF calculator scenario [1] [2] [3]. States and demographic groups hit worst are older adults on the individual market, people with incomes just above Medicaid eligibility (and those >400% FPL who lose subsidies entirely), and residents of high-premium states and localities [4] [3] [5].
1. Who stands to lose the most — the age factor: older enrollees face the steepest sticker shock
Older Marketplace enrollees (especially those aged 50–64) will disproportionately bear higher unsubsidized premiums because age is a major pricing factor in the individual market; KFF maps show that among people with incomes above 400% of the federal poverty level, just over half are ages 50–64 and would therefore face the highest out‑of‑pocket premium hikes when enhanced credits expire [4]. Bipartisan Policy Center examples underscore this: a 60‑year‑old couple at about 402% FPL could see annual benchmark premiums rise by roughly $22,600 in 2026 without the enhanced credits [6].
2. Income bands: middle‑income households above Medicaid thresholds and those over 400% FPL
People with incomes just above Medicaid expansion cutoffs and those between roughly 150–400% FPL are heavily represented among current enrollees and would see large relative increases; nearly half of marketplace enrollees have incomes between 100–150% FPL and a further 28% between 150–250% FPL, meaning many low‑ and moderate‑income households benefit now and would pay substantially more if enhancements lapse [3]. Those above 400% FPL who currently receive expanded help could lose subsidies entirely and face the largest absolute dollar increases, particularly older adults and residents of pricey regions [4] [3].
3. Geographic variation: high‑premium states and localities will be worst hit
State and local differences matter: KFF’s mapping and insurer filings show the expiration’s impact varies by place because unsubsidized premiums differ widely. At several income cutoffs, a 60‑year‑old would see benchmark premiums at least double in dozens of states if enhancements lapse; insurer filings in Vermont, Oregon, Washington and DC suggest insurers already built an average additional 4% onto proposed 2026 premiums to account for expected expiration [4] [7] [5].
4. Coverage and macro effects: millions could become uninsured and the economy would feel it
Multiple analyses project large coverage losses and secondary economic effects. The CBO estimated the uninsured could rise by about 3.8 million annually on average over 2026–2034 without extension; the Urban Institute and Commonwealth Fund present larger near‑term shocks—between roughly 4.8 million and as many as 7.3 million losing ACA coverage with 4.8 million becoming uninsured under one Urban Institute scenario cited by Commonwealth Fund [8] [2]. Commonwealth Fund also ties these coverage losses to potential job impacts and a projected $31 billion decline in federal marketplace spending in 2026 [2].
5. Why premiums rise even for people who still qualify for some subsidies
Premium hikes stem from two mechanisms: the statutory rollback of enhanced subsidy formulas raises required contribution caps, and insurers expect a “morbidity” or adverse selection effect if healthier enrollees depart, which pushes up gross premiums; CBO projects gross benchmark premiums would increase by about 4.3% in 2026 and insurers nationwide proposed median increases around 18% for 2026, with a portion attributed to subsidy expiration [9] [10]. Insurer filings examined by KFF and Health System Tracker show parts of proposed rate increases explicitly tied to expected expiration [5] [10].
6. Political and policy context — tradeoffs and numbers
Extending the enhanced credits reduces premiums and the uninsured but increases federal spending. Bipartisan Policy Center notes a CBO estimate that making enhancements permanent would add roughly $350 billion to the federal deficit over 2026–2035 while increasing insured counts; the CBO baseline assumes expiration absent new law [6]. Analysts and advocacy groups emphasize the human and system impacts of letting subsidies lapse, while budget hawks note the fiscal cost of permanence [6] [9].
Limitations: available sources do not provide a single uniform state‑by‑state ranking in this dataset; instead, analyses combine national projections, insurer filings in selected states, and KFF mapping to identify likely hotspots and demographic groups (not found in current reporting). Different models produce different estimates of coverage loss (CBO vs. Urban Institute vs. Commonwealth Fund), so exact counts vary by methodology [8] [2] [9].
Bottom line: Middle‑income households above Medicaid cutoffs, those over 400% FPL (particularly older adults), and residents of high‑premium states face the biggest financial blows if enhanced ACA premium tax credits expire—driving millions toward uninsurance and prompting insurers to bake higher rates into 2026 filings unless Congress acts [4] [3] [2].