Which states would see the largest coverage losses if 2026 ACA subsidies end, and why?
This fact-check may be outdated. Consider refreshing it to get the most current information.
Executive summary
If enhanced ACA premium tax credits expire at the end of 2025, nonpartisan and research groups project millions would lose marketplace coverage: the Congressional Budget Office estimates an average of about 3.8 million people would lose insurance annually from 2026–2034 (with a 4.3% jump in benchmark premiums in 2026), while other analyses range higher—Urban Institute estimates as many as 7.3 million losing marketplace coverage with 4.8 million becoming uninsured [1] [2]. States that stand to see the largest coverage losses are those with high pre-subsidy marketplace premiums, large numbers of marketplace enrollees, and no Medicaid expansion—conditions repeatedly highlighted in reporting and modeling [3] [4] [2].
1. Where the shock would be concentrated: high-premium, high-enrollment states
Modelers and reporting point to states with both large marketplace rolls and high pre-subsidy premiums as the most exposed, because bigger enrollee counts multiply any percent loss and higher premiums mean subsidies did more heavy lifting there; HealthInsurance.org flagged the ten states projected to have the highest pre-subsidy marketplace premiums as particularly vulnerable, and the Urban Institute/Commonwealth Fund analysis allocated state‑level losses using 2025 enrollee data [5] [2]. The AJMC summary likewise warns that every state could see rises in uninsured rates but calls out non‑Medicaid‑expansion states and high‑premium areas as likely to have the largest increases [3].
2. Why Medicaid expansion status matters
States that did not expand Medicaid before the ACA leave a coverage gap for people under about 138% of the federal poverty level; several sources say those states would likely see larger insurance losses because fewer residents who lose marketplace affordability can fall back into Medicaid [3] [5]. KFF and others emphasize that the enhanced credits enabled many near‑poor enrollees to keep plans; reversion to pre‑ARP rules would restore the subsidy cliff and hurt those in non‑expansion states most [3] [4].
3. The role of the “subsidy cliff” and older enrollees
The temporary ARP/IRA enhancements removed the hard cutoff at 400% of the federal poverty level and capped maximum premium contributions; if the enhancements expire, the subsidy cliff returns and older adults in high‑cost areas face especially steep increases because age‑rated premiums are higher—multiple accounts note older enrollees and those in high‑premium states gained the most from the ARP changes and therefore stand to lose the most [5] [6] [7].
4. Competing estimates and what they mean for particular states
Estimates vary: CBO’s average‑annual figure is about 3.8 million losing coverage from 2026–2034 while the Urban Institute/Commonwealth Fund projection using 2025 enrollment counts estimates up to 7.3 million losing marketplace coverage with 4.8 million becoming uninsured—differences reflect modeling choices and baseline enrollment assumptions [1] [2]. Those divergent totals mean state‑level impacts will depend heavily on each model’s inputs: a state with many marketplace enrollees and large average tax credits will show up as a big loss under both approaches, but the absolute numbers will differ [2] [1].
5. Real‑world indicators already visible at the state level
State reporting shows concrete examples: Connecticut reports nearly 32,000 enrollees who qualify for the enhanced subsidy and would completely lose assistance next year, with another 111,000 seeing reduced support—illustrating how one smaller state can still face substantial coverage and budget consequences [8]. These state snapshots validate the broader modeling: losses concentrate where subsidies and enrollment were largest [8] [3].
6. Downstream consequences that amplify state vulnerability
Analysts warn that premium spikes and coverage losses would ripple into hospitals, clinics and state budgets: CBO projected benchmark premiums would rise (4.3% in 2026) and the Commonwealth Fund flagged job losses and significant uninsured increases that strain safety nets; states with fragile rural health systems or thinner provider networks are therefore more exposed to harm beyond the raw enrollment drop [1] [2] [3].
7. Limits of current reporting and the political variable
Available sources document exposure factors—enrollee numbers, pre‑subsidy premiums, Medicaid expansion status—and provide state‑level snapshots, but they do not supply a single, definitive ranked list of “top states” in these excerpts; different models produce different state tallies and outcomes [1] [2] [5]. The political question—whether Congress will extend or modify the credits before they lapse—remains decisive and is discussed in state reporting, but the sources do not settle whether or how lawmakers will act [8] [3].
Bottom line: states with large marketplace populations, high average pre‑subsidy premiums, and without Medicaid expansion are the likeliest to see the biggest increases in uninsured residents and coverage churn if enhanced 2025‑era ACA subsidies expire—though the scale of loss varies across credible models from a few million nationally (CBO) to several million more in other estimates [1] [2] [5].