What states or markets would see the largest coverage losses if subsidies end?
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Executive summary
The end of enhanced ACA premium subsidies on Jan. 1, 2026 would drive large coverage losses concentrated in states with high pre-subsidy premiums and large Marketplace enrollments; Urban Institute modeling cited by the Commonwealth Fund estimates 7.3 million people would lose marketplace coverage and 4.8 million would become uninsured if the enhancements lapse [1]. State-by-state impacts will vary: analyses flag high-cost states (including a top-ten list of states with the highest pre-subsidy premiums) and specific examples such as Connecticut — where the state exchange estimated average premiums would rise by about $198 per month if subsidies expire [2] [3].
1. Where the pain will be worst: high-premium states and older enrollees
Independent analysts and state exchanges point to states with the highest average pre-subsidy premiums as those likely to see the biggest coverage losses and premium shock; HealthInsurance.org identified the ten states projected to have the highest pre-subsidy Marketplace premiums in 2026 and focused on older enrollees age 55, a group that will be especially exposed because older adults face higher baseline premiums and lose more assistance when enhancements end [2]. AJMC notes that in “high-cost states” premiums for some families could exceed $1,000 per month after the subsidy reversion [4].
2. Magnitude: millions affected and large average premium increases
Macro estimates predict broad, national effects: Urban Institute researchers, summarized by the Commonwealth Fund, project 7.3 million people would lose marketplace coverage in 2026 and 4.8 million would become uninsured, with average marketplace enrollee out-of-pocket premium costs rising from $888 in 2025 to $1,904 in 2026 — a 114% increase [1]. Harvard Kennedy School highlighted a similar doubling in average annual premiums for the “average subsidized household,” from $888 to $1,904 per year [5].
3. State examples and local estimates: Connecticut and others
State marketplaces have produced localized estimates showing steep increases. Access Health CT estimated Connecticut residents could see premiums rise by an average of $2,380 per year (~$198/month) and a household of four could face over $10,000 more annually if enhanced subsidies lapse [3]. HealthInsurance.org’s state-level work and its focus on the ten highest-premium states show how geographic variation in premiums translates into uneven coverage loss risk [2].
4. Who is most likely to lose coverage: middle-income and older shoppers
Multiple sources identify middle-income households, older adults and early retirees as particularly at-risk groups. AJMC emphasizes that middle-income earners and older adults could suddenly lose eligibility for meaningful premium assistance and face large monthly bills in high-cost states [4]. HealthInsurance.org illustrates how households just above the 400% FPL threshold face a “subsidy cliff,” with dramatic jumps in premiums for older couples in lower-cost regions as well [6].
5. Economic ripple effects: uninsured growth and broader fiscal impacts
Loss of coverage will have downstream effects beyond individuals. The Commonwealth Fund piece cites estimates that tens of billions in federal subsidy reductions would lead to expanded uncompensated care burdens and even job impacts — modeling projected 340,000 jobs lost tied to the subsidy expiration scenario [1]. The Harvard Kennedy School commentary stresses that state and local governments often shoulder increased costs through public hospitals and Medicaid when more people become uninsured [5].
6. Political context and timing: Senate action and open enrollment constraints
The immediate policy context matters: Reuters reported the Senate rejected competing proposals on Dec. 11, 2025, leaving roughly 24 million people exposed to higher premiums beginning Jan. 1 [7]. That timing complicates relief: open enrollment and insurer rate filings occur on a schedule that makes mid-season fixes difficult, and several outlets warned that delayed congressional action would worsen implementation problems [8] [1].
7. Competing viewpoints and limits of available analysis
Sources broadly agree that losers will be concentrated in high-premium states and among older and middle-income enrollees, but they diverge on magnitude and distributional detail: state exchanges (Connecticut) provide concrete local dollar impacts [3], while national models from the Urban Institute/ Commonwealth Fund give large aggregate estimates of coverage loss [1]. Available sources do not mention a definitive, universally agreed list of the single worst-hit states by number of lost enrollees; HealthInsurance.org’s top-ten pre-subsidy premium list is the closest state-level ranking referenced here [2].
Limitations: this reporting relies on projections and state estimates produced before final 2026 rate filings; real-world enrollment responses and any last-minute federal action could materially alter outcomes [2] [1].