Which states and demographic groups stand to lose the most coverage if Congress fails to extend enhanced subsidies?
Executive summary
If Congress fails to extend the enhanced Affordable Care Act (ACA) premium tax credits, coverage losses will be concentrated in a handful of states that built large marketplace populations under the expanded subsidies and among demographic groups whose affordability protections disappear — notably middle‑income households just above prior subsidy limits, older adults, small‑business owners and lower‑income people who currently enjoy very low net premiums (and could become uninsured) [1] [2] [3].
1. States with the most to lose: eight stand out
Analysts project the steepest drops in subsidized enrollment in Georgia, Louisiana, Mississippi, Oregon, South Carolina, Tennessee, Texas and West Virginia — eight states that would each see marketplace subsidy enrollment fall by more than half if enhanced credits expire, according to the Urban Institute’s 2025 modeling that estimates a 4.8 million rise in the uninsured as a result [1]. Multiple outlets repeat this finding and map it to surging enrollment patterns during the enhanced period, noting that states with the largest absolute enrollment gains in recent years (including many that lean Republican) face some of the biggest near‑term coverage shocks [4] [5]. State‑level examples from reporting show California and Mississippi already reacting to the cliff: California saw new sign‑ups drop sharply and Mississippi faces an expected mass opt‑out, underscoring how state markets and outreach matter in buffering the shock [6] [7].
2. Who within states faces the biggest cut — the middle‑income “cliff” cohort
The expiration restores a so‑called subsidy cliff that cuts off premium tax credits for households whose income exceeds 400% of the federal poverty level (FPL), meaning someone just $1 over the threshold can lose all assistance; KFF and other analysts show that middle‑income adults who benefited under the temporary expansions would face premium bills that can more than double or become unaffordable [8] [9]. Modeling and examples make the point starkly: a 60‑year‑old near 400% FPL could see annual premiums jump from a subsidized few thousand to double‑digit thousands without the enhancements, turning market coverage effectively unaffordable for many in this band [10] [11].
3. Older adults and small‑business‑connected enrollees are disproportionately vulnerable
Because the ACA allows age‑based rating, older adults — especially those in their late 50s and 60s — face much larger absolute premium increases when subsidies fall away; briefs quantify scenarios where older couples pay a disproportionate share of income for coverage absent enhanced credits [11]. Small business owners and employees of small firms are also overrepresented on the marketplaces because they are less likely to have employer coverage, so the lapse hits that cohort harder than workers in large‑firm jobs that typically offer insurance [10].
4. Lower‑income enrollees could lose “fully subsidized” coverage and become uninsured
Enhanced credits during the pandemic drove net premiums toward zero for some lower‑income households; research warns that many of those now fully subsidized will face positive net premiums or leave coverage entirely if federal help disappears, a mechanism contributing to the Urban Institute’s projection of millions more uninsured [1] [3]. The Congressional Research Service and others emphasize both the lower‑income group losing full subsidy protections and higher‑income households losing eligibility as dual sources of affordability pressure [3].
5. Political and policy ripple effects: states and markets respond unevenly
Some states have adopted stopgaps — New Mexico fully replaced expired subsidies for 2026 and Colorado allocated funds to stabilize premiums — while others lack fiscal room to backfill, amplifying geographic disparities in coverage loss [12]. Observers also flag political consequences: because enrollment growth during the enhanced period occurred heavily in states that supported the Republican presidential candidate, opponents of federal extensions face potential electoral fallout as voters feel premium spikes and coverage churn [5]. Analysts warn that insurers’ rate filings and market dynamics could further amplify losses if healthier enrollees drop coverage, raising premiums for remaining enrollees [13] [4].
Limitations: available analyses focus on 2026 projections and marketplace enrollees; sources do not provide a comprehensive, person‑level breakdown beyond the cited cohorts and states, so other localized pockets of vulnerability may exist that are not documented here [1] [8].