Which income groups and states stand to lose the most financial help when ACA premium tax credit expansions expire?
Executive summary
Millions of Americans who buy coverage on ACA marketplaces will pay substantially more or lose subsidies if enhanced premium tax credits (ePTCs) expire after 2025: analyses estimate between roughly 7.3 million and 18–20 million people would be affected in different ways — for example, Urban Institute/CBO-linked estimates project about 7.3 million losing subsidized coverage and 4.8 million becoming uninsured [1] [2], while other commentators cite impacts on roughly 18–20 million enrollees facing large premium increases [3] [4]. Low- and middle‑income households, people in non‑Medicaid‑expansion states, and those just above the former subsidy cliff (above 400% of FPL) stand to lose the most financial help [5] [6] [7].
1. Who benefits now — and why the loss would hit lower incomes hardest
The enhanced PTCs, enacted in ARPA and extended through 2025 by later legislation, lowered the share of income people must pay for benchmark plans and expanded eligibility to households above 400% of the federal poverty level, producing larger subsidies especially for lower‑income enrollees; nearly all marketplace enrollees receive credits and many have incomes at or below 200% FPL [8] [9]. Analysts show the ePTCs target relief to those with the lowest incomes and that expiration will therefore raise net premiums most sharply for low‑ and middle‑income households who depend on them [9] [7].
2. How many people and which income groups would be most affected
Different studies offer different tallies but converge on heavy impacts concentrated among subsidy recipients. Urban Institute–informed projections cited by research estimate roughly 7.3 million people would lose subsidized marketplace coverage and about 4.8 million would become uninsured if ePTCs lapse [1] [2]. Other analyses and stakeholder statements emphasize far larger numbers facing big premium increases — for example, reporting that 18 million people could be impacted or that 20 million might see average premium hikes of about 75% [3] [4]. Middle‑income people just above 400% FPL also lose substantial help because the enhancements removed the prior cliff; those over 400% could see average premiums rise by thousands of dollars annually without the ePTCs [6] [7].
3. State geography: non‑expansion and high‑cost states stand to lose most
Researchers point to states that did not expand Medicaid as facing outsized harm because more residents there rely on marketplace subsidies rather than Medicaid; the Commonwealth Fund and others list non‑expansion states such as Alabama, Florida, Georgia, Idaho, South Carolina, Tennessee, and Texas among those likely to suffer bigger coverage and economic losses if the credits expire [5]. Insurer rate filings in places like Vermont, Oregon, Washington and DC already show expectations that expiration would raise premiums — filings that give an early signal that state‑level premium impacts will vary with insurer assumptions and local markets [10].
4. How much would premiums and household costs change?
KFF, Peterson‑KFF and Bipartisan Policy Center estimates find average net premium payments would climb sharply without ePTCs: KFF projects net premiums could more than double on average and models show average out‑of‑pocket premium increases in the thousands for some middle‑income households [11] [12] [6]. Peterson‑KFF and insurer filings describe insurers building extra premium increases into 2026 rate requests in anticipation of the subsidy change [10] [11].
5. Wider economic and health-system fallout
Analysts warn of knock‑on effects: lost coverage and higher uncompensated care, state revenue and job impacts, and more uninsured people seeking emergency care. One projection ties ePTC expiration to increased uncompensated care and estimates of hundreds of thousands of jobs and billions of dollars in uncompensated care and economic losses [1] [2]. The exact scale depends on whether Congress acts, state responses, and how insurers price 2026 plans [3] [10].
6. Disagreements, uncertainties, and what the sources do not say
Estimates diverge: some sources emphasize millions facing higher premiums but fewer becoming uninsured, while others project millions losing coverage and becoming uninsured [3] [1] [4]. Early insurer filings are limited to a subset of states and may not reflect national patterns [10]. Available sources do not mention exact household‑level outcomes for every state ZIP code or the final 2026 rate approvals nationwide; they also do not settle on a single definitive national headcount of people losing coverage because methodologies differ [10] [2].
7. Bottom line for readers and policymakers
If Congress lets the enhanced credits expire, the clearest and best‑documented consequence is substantially higher net premiums for subsidy recipients and disproportionate harm to low‑ and middle‑income households and residents of non‑Medicaid expansion states; independent projections quantify this as millions affected, with specific estimates ranging from several million people losing subsidized coverage to broader tallies of 18–20 million facing major premium increases [5] [3] [4]. Policymakers choosing whether to extend or replace the ePTCs will determine whether those projected premium spikes and coverage losses materialize [8] [11].