How would replacing the ACA in 2026 impact health insurance coverage?

1. Stark Numbers: How Many People Could Lose Coverage — and Why This Matters

Analysts offer a wide range of projected coverage losses because different scenarios assume different policy actions; the Congressional Budget Office (CBO) modeled a comprehensive repeal of mandate penalties and subsidies and projected uninsured rates could rise by roughly 18 million in the first year and as many as 32 million by 2026, driven by doubled premiums and shrinking insurer participation ^[2]. Other non‑CBO estimates place the range much lower — roughly 3–5 million people losing coverage if the primary change is expiration of enhanced premium tax credits rather than a full repeal ^{[4] [1]}. The divergence reflects which elements of the ACA policymakers target: ending enhanced subsidies disproportionately affects affordability for subsidized enrollees, while removing market protections and subsidies together causes broad market collapse, producing much larger uninsured counts ^{[3] [5]}.

2. Premium Shock: How Costs Would Rise for Consumers Who Keep Plans

Models agree that ending enhanced subsidies or repealing the ACA would produce substantial premium increases for nongroup (individual) plans. The CBO found premiums could jump 20–25% initially and potentially double by 2026 under broad repeal scenarios, mainly because healthier enrollees would exit, leaving riskier pools and raising costs ^[2]. KFF and other health policy analyses estimate that if enhanced premium tax credits expire, average annual premium payments for subsidized enrollees could more than double, with typical monthly premiums rising from levels like $888 per year to roughly $1,904 annually for those who remain enrolled, generating outsized hardship for low‑ and moderate‑income households ^{[3] [6]}. Higher premiums would thus create both coverage and financial distress consequences across income groups, especially older adults and people ineligible for Medicaid.

3. Market Fallout: Insurer Participation, Plan Availability and State Economies at Risk

A common finding is that insurer participation in the nongroup market would fall sharply under scenarios that remove subsidies and weaken market rules; the CBO warned that up to three‑quarters of counties could have no insurers in some projections, as carriers withdraw from unprofitable markets ^[2]. Reduced competition would further increase premiums and narrow plan choices, compounding access problems even for consumers who can pay higher premiums. State economies could suffer as uncompensated care rises and hospitals face financial pressure; analyses estimate job losses and state GDP declines tied to reduced coverage and higher uncompensated care, with one projection suggesting hundreds of thousands of jobs lost and multi‑billion dollar state GDP impacts if subsidies expire ^{[1] [5]}. These market effects mean harms extend beyond insured individuals to providers, insurers, and local economies.

4. Who Bears the Brunt: Disparate Impacts Across Age, Income and Geography

All sources identify disproportionate harms to younger adults, low‑income families, and older non‑Medicaid adults. Younger, healthier people are most likely to drop coverage when premiums rise, eroding risk pools and increasing costs for remaining enrollees ^{[4] [2]}. Low‑income enrollees who rely on premium tax credits face the steepest relative cost increases if enhanced subsidies expire, whereas Medicaid‑eligible populations would be insulated only where states maintain or expand Medicaid ^{[3] [7]}. Geographic variation matters: states with thin insurer participation or weaker safety‑net systems would see larger coverage and access declines, and interstate regulatory changes or rollback of Essential Health Benefits could deepen disparities among states ^[8].

5. Policy Choices Determine the Outcome: Not a Single Inevitable Path

The wide spread of estimates underscores that 2026 outcomes hinge on legislative and regulatory decisions: whether Congress allows enhanced premium tax credits to expire, repeals core market protections, or restructures subsidies and benefits will shape coverage losses, premium changes, and market stability ^{[6] [2]}. Analyses emphasize that modest changes (ending enhanced credits) produce millions losing subsidies and facing doubled premiums on average, while full repeal yields dramatically larger coverage loss and systemic effects ^{[9] [5]}. Stakeholders advance clear agendas—insurer and provider analyses stress market stability and uncompensated care costs, while proponents of repeal emphasize consumer choice and reduced federal spending—so the observable outcomes will reflect both political decisions and regulatory implementation ^{[7] [8]}.