Which states or populations would face the largest coverage losses if credits end in 2026?

1. Who loses most: a short list of states facing the biggest drops

The Urban Institute’s state-level simulation finds eight states where subsidized Marketplace enrollment would fall by over 50% if the enhanced credits expire: Georgia, Louisiana, Mississippi, Oregon, South Carolina, Tennessee, Texas, and West Virginia ^[3]. Those eight are singled out because they combine large numbers of people enrolled on the Marketplace with relatively large average subsidies in 2025, so removing the enhancements drives steep enrollment and coverage losses ^[3].

2. National scale: millions affected and premiums that shock budgets

Multiple research groups converge on the scale: Urban Institute’s modeling tied to 2025 enrollment projects 7.3 million fewer people with subsidized Marketplace coverage and 4.8 million losing coverage and becoming uninsured in 2026 ^{[1] [3]}. KFF’s estimate on average premium payments finds Marketplace enrollees’ out‑of‑pocket premium burden rising from $888 in 2025 to $1,904 in 2026—a 114% increase—making many plans unaffordable ^[2].

3. Who within populations would be hardest hit

Analysts highlight older adults and people in states that didn’t expand Medicaid as especially vulnerable. KFF notes older adults face steeper premium rises by age cohort ^{[4] [2]}. RWJF’s modeling finds reductions in spending and increases in uncompensated care would be felt “most acutely in states that have not expanded Medicaid,” amplifying local provider strain where safety nets are thinner ^[5].

4. Racial and economic disparities: evidence of unequal effects

The Center on Budget and Policy Priorities and Urban Institute reporting point to uneven racial and income impacts: Urban Institute projects a 30% increase (about 925,000 people) in the number of Black people uninsured in 2026, the largest rate increase among racial/ethnic groups reported in their synthesis ^[6]. CBPP and Urban Institute stress that marketplace enrollment would decline across every state and congressional district, but losses and uninsured increases will concentrate in lower‑income and historically underserved communities ^{[6] [3]}.

5. Localized examples and insurer signals: how states are already reacting

Insurer rate filings in states like Vermont, Oregon, Washington and DC explicitly attribute a measurable share of 2026 premium increases to the expected expiration—about a 4 percentage‑point boost on top of other upward pressure—showing private carriers already pricing for a sparser, sicker risk pool ^[7]. State exchanges have posted estimates of large dollar increases for residents (e.g., Connecticut estimated $2,380 average annual increase) underscoring that state‑level impact varies and can be extreme ^[8].

6. Healthcare system shocks and fiscal ripple effects

Research from RWJF estimates provider revenue losses and higher uncompensated care if the credits end: roughly $32.1 billion in lost revenue to hospitals, physicians and others in 2026 and a $7.7 billion rise in uncompensated care, with greatest stress in states that didn’t expand Medicaid ^[5]. The Commonwealth Fund used IMPLAN economic modeling to translate enrollment losses into job and provider revenue impacts and finds consequences beyond individual coverage—affecting hospitals, clinics and local economies ^[1].

7. Competing projections and political context

Estimates diverge by methodology: CBO’s December 2024 projection showed a smaller short‑term uninsured increase (about 2.2 million in 2026) than some later Urban Institute and RWJF-linked analyses, while others (AJMC synthesis citing CBO) placed coverage losses in the millions as well—demonstrating debate around magnitude and timing ^{[9] [4] [6]}. Politically, extension hinges on Congress and the White House; Republican leaders have signaled opposition to extending the enhanced credits as currently structured, proposing alternatives like HSAs or direct payments—an implicit agenda to shift from federal subsidies to other mechanisms ^[10].

Limitations and what reporting does not say: available sources do not provide a complete breakdown of exact numbers by every state or demographic subgroup beyond the highlighted examples; state‑by‑state projections beyond the eight listed are in Urban Institute’s detailed tables not reproduced here ^[3]. Policymakers’ choices in late 2025 determine whether these projected losses materialize; insurers’ finalized 2026 rates already incorporate some expectations ^{[7] [8]}.