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Which states will be hardest hit by the end of enhanced ACA subsidies?
Executive Summary
The end of enhanced Affordable Care Act (ACA) premium tax credits would sharply raise Marketplace premiums and strip coverage from millions, with states such as Mississippi, Wyoming, West Virginia and parts of Connecticut among the hardest hit by raw subsidy loss and percentage premium increases. Multiple modelling efforts show millions of people losing Marketplace coverage and several million becoming uninsured, with major differences by state, age group, and income that shape who pays most and which local economies suffer most [1] [2] [3] [4].
1. Who says what — three headline claims that shape the debate
Analysts converge on three core claims: first, millions of people would face higher premiums or lose coverage if the enhanced premium tax credits expire; second, the impact is highly uneven across states and congressional districts, with some jurisdictions facing extraordinarily large percentage increases; and third, certain demographic groups — notably early retirees and older adults above 400% of the federal poverty level — would see the biggest dollar increases. These claims are repeated across independent trackers and modeling tools. The Urban Institute flagged Mississippi as the state with the largest share of enrollees currently receiving enhanced credits, while district-level analysis highlights outsized percentage increases in places like Wyoming, West Virginia and parts of Connecticut [1] [2] [5]. Fiscal and economic briefs extend those coverage projections into macroeconomic effects, spotlighting downstream job and state GDP impacts [3] [6].
2. Which states and districts stand to lose most — raw losses and percentage spikes
State-level and district-level work shows different metrics of harm. The Urban Institute’s state breakdown places Mississippi at the top by share of enrollees reliant on enhanced credits, meaning a broad-based exposure to subsidy withdrawal [1]. Congressional-district modeling translates that exposure into dramatic percentage premium increases for a benchmark 60‑year‑old couple, with districts in Wyoming, West Virginia and Connecticut showing increases of more than 500 percent, while New York districts show much smaller changes because of community-rating and other market factors [2]. These contrasting metrics matter: a state with many subsidized enrollees (high absolute exposure) can differ from a district where a specific demographic sees massive percentage changes. Policy design therefore determines whether headline harms appear concentrated geographically or demographically [1] [2].
3. Which people will be hit hardest — age, income, and retiree risk
Analysts identify early retirees and older adults, especially those not yet eligible for Medicare, as among the most financially exposed: a 60‑year‑old couple earning about $85,000 faces very large premium increases in districts modeled by some outlets [5]. Broader briefs add that individuals under age 55 and people with incomes above 400% of the federal poverty level also face significant premium spikes when enhanced credits end, and that low‑ and middle‑income families and groups with historically higher uninsurance risk will be disproportionately affected [4]. That combination of age and income sensitivity explains why the same policy change can create both large percentage increases for particular households and widespread coverage loss for lower‑income enrollees.
4. Scale: how many people, how big the premium shock, and the economic ripple effects
Estimates vary but consistently point to millions of coverage losses and very large average premium increases. One brief projects 7.3 million people leaving Marketplace coverage in 2026, with 4.8 million of them becoming uninsured; other work estimates 3.8 million additional uninsured by 2035 in a different scenario. Average marketplace payments are projected to more than double in some analyses, with increases described as an average jump from about $888 to $1,904 annually or comparable percentage hikes [3] [4]. Modelling also translates coverage and spending drops into state economic contractions, including a $40.7 billion reduction in state economic activity and roughly 339,100 lost jobs in one 2026 estimate, underscoring that subsidy policy has measurable labor‑market and fiscal spillovers [3] [6].
5. Tools, uncertainties, and what the data don’t settle
Calculator tools and policy briefs provide granular estimates but carry caveats: the ACA Enhanced Premium Tax Credit Estimate calculator is explicit that it offers scenario estimates based on IRS 2026 caps and premium assumptions, not definitive future prices [7]. Projections differ by model assumptions about enrollment responses, employer offers, Medicaid churn, and the behavioral response of unsubsidized consumers; those assumptions produce differing totals for people losing coverage (for example, 4.8 million versus 7.3 million) and for the timing of economic effects [3] [6]. Policymaking choices — whether to extend, modify, or replace enhanced credits — determine the outcome, and small modeling differences in age bands or income thresholds create large differences in district‑level percentage changes. The available analyses collectively show clear directional harm from expiration, while also flagging significant model uncertainty around exact state and local magnitudes [7] [4].