How will the 2026 expiration of enhanced premium tax credits affect enrollment and premiums in each state?
Executive summary
If enhanced premium tax credits (ePTCs) expire at the end of 2025, multiple analyses project big effects: subsidized enrollees’ average out‑of‑pocket premium payments would rise about 114% (from $888 in 2025 to $1,904 in 2026) and insurers’ gross benchmark premiums are projected to rise about 4–18% depending on the estimate and state filings (CBO ~4.3%; insurers’ filings and KFF median proposals ~18%) [1] [2] [3]. Models also forecast millions losing coverage — estimates vary from roughly 3.8 million (CBO) to 4.8 million (Urban Institute) to broader figures cited by advocacy groups — and large state variation driven by local premium levels and insurer responses [2] [4] [5].
1. “Two separate shocks: net costs jump, insurers price for sicker risk pools”
When ePTCs end, consumers face a direct loss of subsidies (net premiums rise steeply) while insurers anticipate a less healthy enrollee mix and request higher gross premiums. KFF finds average consumer premium payments would more than double — a 114% increase from $888 to $1,904 — while insurer filings and modeling show additional gross premium pressure: some filings imply an extra 4% on top of other drivers, and insurers’ nationwide proposed rate filings show a median 18% increase for 2026 [1] [3] [6].
2. “How many people could drop coverage — and why estimates differ”
Estimates of coverage loss diverge because models use different enrollment baselines and behavioral assumptions. The Congressional Budget Office projects uninsured counts would rise by about 3.8 million annually in the 2026–2034 window tied to expiration effects, while Urban Institute modeling calibrated to 2025’s record Marketplace enrollment estimates 4.8 million people losing coverage in 2026 alone [2] [4]. Advocacy and policy groups cite larger or cumulative figures (for example, “nearly 22 million” referenced by CBPP for people affected by big cost increases or coverage loss), reflecting broader definitions of who would face dramatic impacts [5].
3. “State‑by‑state variance: local premiums and insurer choices matter”
Early state filings — a small sample from Vermont, Oregon, Washington and DC — show insurers attributing an average of about a 4% premium increase to the expected expiration, but individual insurer impacts range from 1% to 7%+ depending on local conditions [3] [7]. Independent reporting notes that states with high baseline premiums or older enrollee mixes (for example, Wyoming, West Virginia, Alaska in one map analysis) would see the steepest spikes for particular age/income groups if credits lapse [8]. In short, the national averages mask substantial state and local variation driven by existing premium levels, age mixes, and insurer market power [3] [8].
4. “Who loses most: age, income and the ‘over‑400% FPL’ cliff”
Enhanced credits had two big design effects: they capped premium shares of income and extended eligibility above 400% of the federal poverty line. If ePTCs expire, people above 400% FPL who became newly eligible will lose subsidies entirely; Urban Institute projects net premiums for those above 400% FPL would nearly double in 2026 (from $4,436 to $8,471 in their scenario) [4]. Older marketplace enrollees (50–64) will be hit hardest among higher‑income buyers because age raises unsubsidized premiums substantially [9] [8].
5. “Macro ripple effects: federal budgets, uncompensated care, jobs”
Beyond individual and insurer impacts, analysts project wider fiscal and economic consequences. CBO and other analyses suggest expiration would reduce federal subsidy spending but raise uncompensated care costs; Urban Institute and subsequent commentary estimate higher uncompensated care demand (billions of dollars) and job impacts tied to reduced healthcare spending. For example, one analysis updates that federal premium tax credit funding would decline by about $31 billion in 2026, with modeled job losses and higher uncompensated care demand cited in follow‑on studies [10] [11].
6. “Limits, disagreements and political context”
Sources agree on the directional effects (higher net premiums, upward pressure on gross premiums, increased uninsurance) but disagree on magnitude. Differences stem from modeling choices, which enrollment baseline to use (2024 vs. 2025 record enrollment), and whether insurer proposed rate filings translate directly into final rates [1] [3] [4]. Policy actors bring implicit agendas: advocacy groups emphasize coverage losses to press for extensions [5], insurers highlight cost pressures to justify filings [7], and bipartisan think tanks stress tradeoffs between coverage and federal costs [9].
7. “Bottom line for consumers and states”
If Congress does not extend ePTCs, expect large increases in what consumers pay (median modeled jumps far above 100% for subsidized enrollees), meaningful upward pressure on insurer premiums (CBO ~4.3% average gross effect; insurer filings and KFF median proposals point to larger increases in many places), and millions more uninsured — with state outcomes varying widely by local premiums, demographics, and insurer decisions [1] [2] [3] [4]. Available sources do not mention precise enrollment or premium changes for every individual state; early filings offer only a partial look and final 2026 rates and enrollment will depend on regulators, insurer decisions, and any Congressional action [3] [7].
If you want, I can map the KFF/Urban/CBO figures onto a specific state or ZIP code using the KFF calculator and the early insurer filings to show expected net premium changes for typical age/income profiles (sources: [12]; [7]0).