Fact check: Which states will be most impacted by the loss of ACA subsidies?

1. Sharp Coverage Losses Loom for Certain Southern and Plains States — Who Makes the Short List?

A September 2025 analysis explicitly identifies eight states—Georgia, Louisiana, Mississippi, Oregon, South Carolina, Tennessee, Texas, and West Virginia—where subsidized Marketplace enrollment would fall by more than half if enhanced premium tax credits expire, signaling concentrated exposure among those states’ low- and moderate-income populations ^[1]. This claim stresses enrollment sensitivity to federal subsidy levels and implies that state-level uninsured rates and financial strain on hospitals and safety-net providers could rise quickly if Congress allows enhanced credits to lapse. The study’s publication date (2025-09-16) makes it the most recent targeted listing in the packet ^[1].

2. Another Study Flags High-Premium States — A Different Vulnerability Map

A June 2025 investigation takes a different angle, identifying Vermont, Alaska, West Virginia, Wyoming, New York, Connecticut, and Nebraska as most exposed because they have the highest premiums and therefore would see the largest absolute premium increases without subsidies ^[2]. This alternative list highlights premium magnitude, not enrollment share, as the risk driver: where baseline premiums are high, subsidies do more heavy lifting, so removing them produces steep sticker shocks. The difference between lists illustrates how analytic choices—counting enrollment declines versus premium increases—produce different “most impacted” states ^[2].

3. Evidence from Past Policy Changes Shows Behavioral Shifts Among Enrollees

Historical episodes—such as termination of cost-sharing reduction payments—demonstrate that changes in subsidy flows alter plan selection and can increase premiums, prompting many low-income enrollees to shift to cheaper bronze plans rather than silver offerings ^{[3] [4]}. That pattern indicates the loss of enhanced premium tax credits would likely not just reduce enrollment but also change plan mix, increasing underinsurance and out-of-pocket exposure for remaining enrollees. These behavioral findings are drawn from studies published in 2024 and earlier and show mechanisms that could compound enrollment declines from subsidy loss ^{[3] [4]}.

4. Federal vs. State Marketplace Status and Medicaid Expansion Matter — Why the Geography Varies

The analyses imply that federally facilitated Marketplaces and states that didn’t expand Medicaid may show larger marketplace enrollment sensitivity, because more low-income residents depend on Marketplace subsidies rather than Medicaid ^{[5] [6]}. This institutional distinction helps explain heterogeneity: a state with many subsidized enrollees and no Medicaid expansion will have a higher share at risk, whereas expansion states may blunt the net coverage loss. The studies collectively stress that state policy choices interact with federal subsidies to shape vulnerability ^{[5] [6]}.

5. Aggregate Contribution of Marketplace Subsidies to Coverage Gains — The Bigger Picture

A March 2025 synthesis finds 55% of ACA-related coverage gains from 2013–2023 came from Marketplace subsidies, with 37% from original subsidies and 19% from American Rescue Plan (ARP) enhancements, while Medicaid accounted for 45% ^[7]. This proportional split underscores the systemic importance of subsidies to national gains in coverage; removing enhanced credits would therefore reverse a meaningful share of the Marketplace-driven improvements. The datedness of different inputs matters, but the March 2025 synthesis provides a mid-2025 benchmark for attributing coverage effects ^[7].

6. Contrasting Methodologies Produce Different State Rankings — What Analysts Omit

The conflicting state lists reflect methodological differences: one analysis emphasizes projected percentage declines in subsidized enrollment, another emphasizes absolute premium increases tied to high-cost markets, and others highlight behavioral responses to subsidy channel changes ^{[1] [2] [3]}. Absent in the packet are uniform adjustments for state-level demographics, insurer competition, and year-to-year premium dynamics; these omissions can tilt results. Recognizing these gaps clarifies why no single “most impacted” roster is definitive without alignment on metrics and time frames ^{[2] [3]}.

7. Agenda Signals and Source Context — Reading the Studies Carefully

The packet includes recent policy-focused reports and academic analyses; each source carries potential agendas—advocacy groups emphasize coverage loss numbers, marketplace trackers stress premium volatility, and academic work foregrounds behavioral mechanisms ^{[1] [2] [3]}. Readers should note publication timing—most recent targeted state list is September 2025—when weighing current risk. The studies’ varied emphases show that policy framing (coverage counts vs. premium shock) shapes which states appear most vulnerable ^{[1] [2] [3]}.

8. Bottom Line: Multiple States Are at Serious Risk, but Which Ones Depends on the Lens

All analyses agree that loss of enhanced ACA subsidies would materially worsen affordability and reduce coverage, but whether Georgia, Louisiana, Mississippi, Oregon, South Carolina, Tennessee, Texas, West Virginia or Vermont, Alaska, Wyoming, New York, Connecticut, Nebraska are “most impacted” hinges on whether one prioritizes enrollment declines or absolute premium increases ^{[1] [2]}. Policymakers and stakeholders must therefore assess both enrollment exposure and premium magnitude—plus state policy context—to target mitigation effectively ^{[7] [3]}.