States facing steepest coverage losses as ACA subsidies expire

Enhanced ACA premium tax credits expire Dec. 31, with congressional efforts to extend them stalled and no resolution in sight.

The enhanced subsidies, introduced under the 2021 American Rescue Plan Act, increased subsidy amounts and expanded marketplace eligibility to households earning more than 400% of the federal poverty level, capping out-of-pocket premiums for a benchmark plan at 8.5% of income. Previously, premium tax credits were available only to enrollees earning between 100% and 400% of the federal poverty level.

Since the enhanced credits took effect, ACA marketplace enrollment grew to 24.3 million in 2025. As of Dec. 23, more than 15.6 million people have enrolled in plans on federally run ACA exchanges for 2026, down from about 16 million at the same point last year. Insurers have implemented the highest ACA rate increases since 2018, with the median premium increase among 318 small group insurers across all 50 states and Washington, D.C., at 11% for 2026, according to KFF.

Neither a Democratic proposal to extend the subsidies for three years nor a Republican alternative focusing on health savings accounts survived Senate votes earlier this month. Four House Republicans joined Democrats in signing a discharge petition to force a vote on extending the subsidies, but House rules mean a vote likely won’t occur until lawmakers return to D.C. in January.

Around 4.8 million people will lose coverage without an extension, the Urban Institute estimated in a September report, representing a 21% increase in the uninsured population.

The states facing the steepest coverage losses, ranked by estimated growth in uninsured residents:

1. Mississippi: 65%
2. South Carolina: 50%
3. Tennessee: 41%
4. Texas: 39%
5. Georgia: 39%

Without an extension, total state GDPs would fall by $34.1 billion and total economic output would decrease by $57 billion, according to a March brief from the Commonwealth Fund.

The states facing the largest economic impact, including estimated losses in federal funding:

1. Texas
   Economic output change: −$14.1 billion
   Federal funding loss: −$6.3 billion
   
   
2. Florida
   Economic output change: −$9.5 billion
   Federal funding loss: −$4.2 billion
   
   
3. Georgia
   Economic output change: −$5.5 billion
   Federal funding loss: −$2.5 billion
   
   
4. Tennessee
   Economic output change: −$2.8 billion
   Federal funding loss: −$1.3 billion
   
   
5. Louisiana
   Economic output change: −$2.1 billion
   Federal funding loss: −$968.6 million

The expiration ripple effects would extend across the healthcare industry. Overall employment would decline by 286,000 jobs nationwide in 2026, including 130,000 healthcare positions at hospitals, physician offices, ambulatory care facilities and pharmacies, the Commonwealth Fund found.

The states facing the steepest healthcare job losses:

1. Texas
   Healthcare job losses: 30,800
   Total jobs lost: 69,300
   
   
2. Florida
   Healthcare job losses: 22,100
   Total jobs lost: 49,200
   
   
3. Georgia
   Healthcare job losses: 12,800
   Total jobs lost: 28,400
   
   
4. Tennessee
   Healthcare job losses: 5,800
   Total jobs lost: 13,300
   
   
5. Louisiana
   Healthcare job losses: 5,200
   Total jobs lost: 11,300