Which states and demographic groups would gain or lose coverage if Congress lets 2026 premium tax credits expire?
Executive summary
If Congress allows the enhanced ACA premium tax credits to expire after 2025, analysts estimate millions would lose coverage and most subsidized enrollees would pay far more: Urban Institute projects 4.8 million people would lose marketplace coverage and net premiums would nearly double for some above-400% FPL enrollees (from $4,436 to $8,471) [1]. KFF finds average out-of-pocket premium payments would rise 114%—about $1,016 per enrollee in 2026—and insurers’ early filings and CBO modeling imply average gross benchmark premiums would rise roughly 4–7.7% in initial years due to market effects [2] [3] [4].
1. Who gains and who loses: headline winners and losers
If enhanced premium tax credits expire, people newly eligible under the enhancements—households above 400% of the federal poverty level—would lose subsidies entirely and see the sharpest dollar increases (Urban Institute quantifies net premiums nearly doubling for that group) [1]. Current subsidized enrollees at lower incomes would also pay substantially more out of pocket; KFF estimates average annual premium payments for subsidized enrollees would jump from $888 in 2025 to $1,904 in 2026 (a 114% increase) [2]. Available sources do not mention specific individual states “gaining” coverage if credits expire; instead, reporting focuses on coverage losses and premium increases (not found in current reporting).
2. How many people would lose coverage — and why estimates vary
Estimates differ by modeler: Urban Institute projects 4.8 million people would become uninsured and 7.3 million would lose ACA coverage in 2026 in their scenario [5] [1]. The Congressional Budget Office (CBO) projected a rise in the uninsured by about 2.2 million in 2026 without an extension and noted longer-run average increases of 3.8 million per year across 2026–34 in some analyses [4] [6]. Differences reflect modeling choices: how many people would drop coverage versus switch plans, how much premiums rise, and whether higher premiums push healthy people out of marketplaces [4] [1].
3. Local and demographic patterns: who is most exposed
Older adults on the Marketplace and people in high-premium regions bear especially large increases; among enrollees over 400% FPL, just over half are ages 50–64, so older enrollees face bigger unsubsidized premiums [7]. KFF mapping shows state-by-state variation: in many states premiums and the resulting share of income paid will rise more for 60‑year‑olds than 40‑year‑olds at comparable income shares [7]. Urban Institute and Bipartisan Policy Center analyses emphasize that those above the 400% FPL cutoff and middle‑income families who benefited from the enhancements face the steepest losses [1] [8].
4. Market effects: insurers’ filings and projected premium changes
Insurer rate filings in select early states show carriers frequently modeling an added 3–7% premium increase attributable to the expected expiration; KFF’s review of 23 filings in Vermont, Oregon, Washington and DC found an average 4% premium increase tied to the expiration, while CBO models a 4.3% increase in gross benchmark premiums in 2026 and larger increases thereafter without a permanent extension [3] [4]. KFF and Bipartisan Policy Center note insurers are also proposing overall median rate increases around 18% for other reasons (rising health costs, regulatory shifts), so expiration compounds broader upward pressure [9] [8].
5. Economic and fiscal consequences beyond premiums
Letting credits lapse would reduce federal premium tax credit spending in 2026 by an estimated tens of billions; Commonwealth Fund cites a $31 billion decline in federal funding for marketplace credits in 2026 in one analysis, and modeling suggests second‑order economic impacts—job losses and increases in uncompensated care—could follow [5] [6]. Urban Institute estimates increased uncompensated care and related health system pressures if large numbers become uninsured [6] [1].
6. Political and policy context: why the debate is contested
Analysts and policy groups frame tradeoffs differently: advocates emphasize coverage and affordability losses and point to large enrollment gains driven by the enhancements [2] [1], while fiscal‑conscious discussions (cited by Bipartisan Policy Center) stress budgetary implications and urge offsets if extensions are made [8]. Legislative proposals range from short one‑year extensions to making enhancements permanent; the precise policy choice will determine final distributional impacts [8].
Limitations: All numbers above come from the provided analyses; modeling assumptions and local insurer decisions vary, producing a range of estimates [4] [3] [1]. Specific county‑level winners or any state that would “gain” coverage if credits expire are not identified in the sources (not found in current reporting).