Who would be most affected by the loss of enhanced premium tax credits in 2026 (by income and state)?
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Executive summary
The expiration of the enhanced premium tax credits (ePTCs) at the end of 2025 would sharply raise 2026 marketplace premiums and hit middle‑ and upper‑middle incomes and older enrollees hardest: KFF estimates average premium payments would more than double (a 114% rise, from $888 to $1,904) for subsidized enrollees [1], while KFF and mapping analyses show those just above 400% of the federal poverty level—especially older people and residents of high‑cost states—face the biggest dollar and percentage increases [2] [3].
1. Who loses financial help — the income cutoffs and the “cliff”
The enhanced credits temporarily expanded eligibility above 400% of the federal poverty level and raised subsidy amounts; if they lapse, households above the statutory subsidy cutoff will lose eligibility entirely and face steep, often cliff‑like premium increases [4] [5]. Analyses and calculators updated for 2026 show an outsized effect on households just above 400% of FPL; those families suddenly become ineligible and can see annual premiums rise by thousands of dollars [2] [6].
2. Age multiplies the impact — older enrollees are most exposed
Multiple analyses single out older marketplace enrollees as especially vulnerable because unsubsidized premiums rise with age: among those above 400% FPL, just over half are ages 50–64, and a 60‑year‑old in many states would see premium payments balloon compared with a 40‑year‑old in the same income band [3]. KFF’s examples show older couples can face quadrupling or tripling of net premium costs if enhanced credits expire, as higher gross premiums and the loss of subsidies compound [5] [1].
3. State geography matters — high‑cost and non‑Medicaid‑expansion states fare worse
The burden of expiry is uneven across states: KFF mapping finds the doubling of benchmark silver payments for older enrollees would occur in many states and the District of Columbia at modest income multiples above 400% FPL, and insurer filings in some states attribute an extra 4 percentage points (on average) of 2026 rate increases to the expected expiration [3] [7]. Reporting notes that non‑Medicaid‑expansion states concentrate a large share of the people facing the steepest hikes, leaving fewer fallback coverage options [8] [9].
4. Scale of people and coverage losses — millions at stake
Think in millions: independent estimates foresee large coverage and premium effects if Congress does not act. KFF, Health Affairs, Commonwealth Fund, and the Urban Institute present overlapping projections—KFF and other outlets estimate premium payments more than double on average for subsidized enrollees [1] [2], Health Affairs and others estimate about 22 million people would see higher premium liability and Urban Institute projects 7.3 million fewer people receiving subsidized marketplace coverage and 4.8 million more uninsured in 2026 under expiration scenarios [10] [11].
5. Insurer behavior and second‑order effects — premiums and market risk pools
Insurers price prospectively; filings and insurer statements indicate they anticipate healthier enrollees leaving when subsidies shrink, which drives up gross premiums further—insurer filings in multiple states show an added 1–7 percentage points of premium increases attributed to the expected ePTC expiry [7] [9]. Analysts warn this feedback loop would worsen affordability and could cause market exits that raise costs for remaining enrollees [7].
6. Who’s often discussed but less emphasized in sources
Policy commentaries and guides note the likely headline groups affected: part‑time workers, gig workers, small business owners, and the self‑employed who rely on marketplace coverage rather than employer plans [12] [13]. Sources do not provide a granular, state‑by‑state ranking in a single table within the materials provided here; mapping exercises exist (KFF) but our available excerpts don’t list every state rank or specific counts by income and state (available sources do not mention a complete state-by-state ranked table).
7. Political and economic stakes — budget tradeoffs and local fallout
Analysts frame the choice as a federal budget tradeoff: allowing enhanced credits to lapse reduces federal outlays but would increase uncompensated care and economic drag. The Urban Institute and Commonwealth Fund estimate large fiscal and employment impacts—federal PTC outlays fall while uncompensated care and state revenue losses rise; one brief projects a $26.1–$31 billion reduction in federal credits in 2026 and downstream losses in state tax revenue and jobs [14] [15].
Limitations and what to watch next: estimates vary by model and assumptions about 2026 gross premiums and insurer responses; insurer rate filings provide early state signals but do not cover every market [7] [9]. For a precise, state‑by‑state income‑band table you should consult the full KFF maps and Urban Institute modeling referenced above—those datasets underpin the claims summarized here [3] [11].