Which states would see the largest increase in uninsured rates if ACA subsidies end?
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Executive summary
If enhanced ACA premium tax credits expire at the end of 2025, analysts predict large premium increases and meaningful coverage losses concentrated in higher‑cost states and among middle‑income and older Marketplace enrollees; KFF estimates average Marketplace premium payments would rise 114% and premiums would more than double on average in 2026 absent extensions [1] [2]. The Congressional Budget Office and other analysts project millions could lose coverage and that states with high baseline uninsured risk and high 2026 pre‑subsidy premiums will see the biggest spikes [3] [4] [5].
1. Where the pain would concentrate: high‑cost states and older, middle‑income enrollees
Multiple analyses point to the same pattern: expiration hits hardest where unsubsidized premiums are already high and where many enrollees are in the income bands that would lose the most assistance — notably older adults near retirement age and middle‑income households who benefited from the ARPA/IRA expansions; KFF and advocacy groups single out older adults (ages 50–64) and people above 400% of the federal poverty level as especially vulnerable [2] [6] [7].
2. How analysts identify the “largest increases” by state
Researchers estimate state impacts by combining projected 2026 pre‑subsidy premiums with the distribution of Marketplace enrollees and incomes in each state; healthinsurance.org specifically examined the ten states projected to have the highest average pre‑subsidy Marketplace premiums in 2026 as illustrative of where subsidy losses would be largest [5]. KFF’s state‑level analyses and interactive calculator translate subsidy loss into dollar and percentage increases for families by ZIP code, age and income [1].
3. Expected magnitude: double‑digit percentage jumps and big dollar pain
KFF’s modeling finds premium payments for many would more than double on average next year if enhanced credits lapse — it estimates an average 114% increase in out‑of‑pocket Marketplace premium payments, roughly $1,016 additional per year for a typical subsidized enrollee in its scenario [1] [2]. Broader reporting cites insurer rate filings projecting a median 18% increase in gross premiums driven in part by uncertainty about subsidies, compounding the loss of credits [8].
4. Coverage loss risks: millions at stake
CBO and health policy commentators warn that subsidies’ expiration would shrink enrollment; CBO estimated coverage reductions tied to ending the enhancements and some analyses suggest up to several million people could become uninsured over time if Congress does not act [3] [7] [9]. KFF and other groups emphasize that many who drop coverage would be lower‑cost enrollees, which would raise pre‑subsidy premiums further for those who remain [10] [2].
5. State examples and implicit agendas in the reporting
State‑focused pieces and calculators highlight “high‑premium” states as likely to see the biggest increases [5]. Watch for advocacy framing: pro‑extension groups (KFF, Medicare Rights Center, Commonwealth Fund citations) emphasize affordability and coverage losses, while some policy commentaries and certain regulators argue the budgetary baseline already assumes reversion and frame expiration as deficit savings — those differences reflect differing priorities between affordability advocates and fiscal conservatives [9] [8].
6. What the data do not say directly
Available sources do not list a ranked, definitive table of “top states by uninsured‑rate increase” after subsidy expiration; instead, researchers infer state risk from projected 2026 pre‑subsidy premiums, Marketplace enrollment composition, and income distributions [5] [1]. Specific numeric estimates of uninsured‑rate increases by state are not provided in the materials above — not found in current reporting [1] [5].
7. Practical implications for policymakers and consumers
If Congress does not extend the enhanced credits, consumers in high‑cost states, older Marketplace enrollees, and families above 100% FPL will face steep premium increases and likely higher uninsured rates; insurers’ rate‑setting and market exits could amplify the effect, while employers and alternative coverage mechanisms (e.g., ICHRAs) are likely to be part of the response mix, per employer‑market reporting [4] [11]. Policymakers arguing to extend or make permanent the enhancements stress preventing these state‑level spikes and the projected millions of coverage losses [2] [7].
Limitations: reporting and models vary in methods (KFF’s calculator, CBO projections, state‑level premium projections), so specific state rankings are model‑dependent. For explicit state‑by‑state uninsured‑rate increases, available sources point to likely high‑impact states but do not publish a single authoritative ranking — that data is not found in the current reporting [5] [1].