The fight over enhanced premium tax credits for the Affordable Care Act’s (ACA) marketplace drags on in Congress as crucial deadlines draw near and certain groups stand to be hit the hardest if an agreement to extend the subsidies doesn’t materialize.
Estimates of how many will be impacted by expiring tax credits have ranged from 3 million to more than 4 million enrollees. Based on early projections, this subsection is likely to be younger.
“Young adults would see the greatest increase in uninsurance,” said Matthew Buettgens, senior fellow in the health policy division at the Urban Institute. “These are people who are working and don’t have access to stable coverage through an employer.”
The Urban Institute published an analysis last month that found uninsurance rates among adults aged 19 to 34 would rise by 25 percent, the largest increase across different age groups.
Children would stand to be the least affected — a 14 percent increase in uninsurance rates — because of higher income eligibility through programs like Medicaid and the Children’s Health Insurance Program.
While another provision of the ACA allows for young adults to remain on their parents’ health insurance plans until age 26, Buettgens notes that if doing so was a viable option for them, they wouldn’t have enrolled in the marketplace in the first place. Those who lose coverage because of expiring tax credits are unlikely to have their parents’ plans to fall back on.
Between 2009 and 2023, the uninsurance rate among young adults fell from 31 percent to 13 percent.
Rep. Marjorie Taylor-Greene (R-Ga.), who has spoken forcefully against allowing the subsidies to expire, said her adult children’s premiums will double next year if the issue is not addressed.
Across different racial groups, Black, non-Hispanic people would see the largest increase in uninsurance rates, an estimated 30 percent, with white, non-Hispanic people following closely behind at 25 percent.
Buettgens said this jump would be particularly noticeable in states that haven’t expanded Medicaid coverage through the ACA. The premium tax credits cover individuals who would otherwise have been covered by Medicaid expansion.
The impact will be felt across all income brackets, with the Urban Institute projecting “lower Marketplace enrollment across all income categories in 2026 because of standard [premium tax credits] replacing enhanced [premium tax credits].”
Among people who make 250 percent of the federal poverty level or lower, 23 percent are projected to lose coverage. People who make 400 percent or more than the federal poverty threshold will no longer be eligible for premium tax credits, and about 200,000 people, or 5 percent, within this bracket are projected to become uninsured.
Those in the middle, making between 250 percent and 400 percent of the federal poverty level, will see the largest percent gain in uninsurance, projected at 26 percent.
Not only will consumers be hit, but experts warn that hospitals will be further handicapped by the upcoming deadline.
“Hospitals are already facing uncertainty regarding forthcoming cuts to Medicaid and stress on the Medicaid program. And so, this will just be another increase in the uninsured population, which means, ultimately, greater amounts of charity care and less patients with coverage,” Jeff Wurzburg, former attorney at the Department of Health and Human Services and health care regulatory attorney at Norton Rose Fulbright, told The Hill.
Wurzburg noted that hospitals in red states are more likely to see the brunt of this, as they tend to have higher ACA enrollment rates.
An analysis by the health policy nonprofit KFF found that most ACA market enrollees — 77 percent, or 18.7 million of the 24.3 million enrollees — live in states won by President Trump in the 2024 election.
The enhanced subsidies were born from the COVID-19 pandemic, and opponents to their extension argue they’re unnecessary now. Their unexpected efficacy in boosting insurance coverage, however, means going back to a time before they existed isn’t so simple.
“I don’t think anyone really anticipated how effective these enhancements would be in driving coverage improvement. The fact that there will be 4 million people who lose their health insurance if this policy changes; that’s really what the conversation has to be,” Jessica Altman, executive director of Covered California, previously told The Hill.
Lorelei Salas, former supervision director for the Consumer Financial Protection Bureau, worries that the end of affordable plans through the ACA will usher more inferior products into the market, such as junk plans and payday loans.
“Someone is going to come up with other products in terms of health insurance coverage that are going to possibly put people’s financial lives at risk, but there’s less oversight of those new markets right now,” Salas said.
“A lot of people who are not able to pay those monthly premiums if they double — and then if you actually do have health needs that you cannot wait — you’re going to be on the lookout. You’re going to be searching for something else, for alternatives that are not regulated.”
And this forced migration out of the ACA marketplace and into private plans means the expiring tax credits will impact those who get coverage outside the ACA.
“There are people who are buying non-group coverage outside the marketplace, and they are likely going to face higher premiums as well because of the worsening risk pool in the non-group market,” said Buettgens, adding this is likely to affect people who don’t get their health insurance through the ACA or an employer.