Who will lose out when ACA health insurance subsidies expire?

Some 22 million Americans are set to lose health insurance subsidies by the end of the year. Who are they, and what will happen if the subsidies are allowed to expire?

These subsidies, known as enhanced premium tax credits, lower costs for people who buy their health insurance through Affordable Care Act (ACA) marketplaces (sometimes called Obamacare). They are at the heart of a weeks-long standoff that has shuttered the federal government since Oct. 1. About 80 percent of the people who benefit from them live in states that Donald Trump won in the 2024 presidential election. Many have no idea that their health insurance costs are on track to go up.

Almost everyone who got their health insurance through an ACA marketplace in 2025 received the enhanced premium tax credit, so describing the people who have ACA plans is a good way to get a sense of the people who get the credit.

The typical person with an ACA plan is an adult in their mid-40s with an income between 100 and 200 percent of the federal poverty line, or about $21,000 to $42,000 for a family of two.

Lower-income people with ACA plans will return to the lower subsidy levels from the early years of the ACA if the enhanced credits expire. A smaller group with higher incomes will become responsible for the full cost of their premiums.

Nearly half of the adults on ACA marketplace plans are self-employed, small-business owners or small-business employees, according to an analysis from KFF, an independent health policy research organization. While most Americans get their health insurance through their employer, those who work for small businesses (or themselves) often have to rely on the exchange.

“The Affordable Care Act is specifically designed to fill that gap,” said Jessica Banthin, a senior fellow in the health policy division of the Urban Institute, a think tank.

Not everyone who gets their health insurance through a marketplace is employed. A Washington Post analysis found that about 9 percent are retired people who may not yet be eligible for Medicare and that 6 percent are students. However, only people with an income are eligible for the enhanced premium tax credit.

Democrats have made extending the enhanced credits their main demand to reopen the government. That extension will mostly benefit people living in states where Trump won the 2024 presidential election.

While about 8 percent of the country has their health insurance discounted through an enhanced premium tax credit, that share is much higher in some states. Twenty-four percent of Floridians under 65 benefit from the tax credit, as do 14 percent of Georgians.

The credits are most widely used in the 10 states that did not expand Medicaid eligibility after the ACA was enacted. Without the Medicaid expansion, many lower-income people without employer-sponsored health insurance could get health insurance only through ACA marketplaces.

Marketplace plans became even more popular in those states once the enhanced premium tax credits became available in 2021, bringing costs for some plans down to $0 for people making less than 200 percent of the federal poverty level. Overall enrollment in marketplace health insurance plans nearly doubled, with the greatest gains in states without Medicaid expansions.

When those tax credits expire, subsidies will become less generous for most recipients and will go away entirely for some. KFF estimated that the average premium would more than double when the enhanced version of the tax credits expire. However, those changes look very different across income levels.

If the credit expires, ACA marketplace customers at or near the poverty line would see their premiums jump from $0 to 4 percent of their income for a silver-level plan. A 50-year-old couple in Dallas who made 150 percent of the federal poverty level ($32,000 in 2025) would see their premiums increase to about $1,300 in 2026.

“The cost of health insurance is never going to be low enough for a person who makes just above poverty to be able to afford it,” said Cynthia Cox, vice president of the Program on the ACA at KFF. “If you want that person to have health insurance, then there needs to be financial assistance.”

Even if a family can afford the increased premiums, the administrative hurdle of submitting payments as low as $1 could cause as many as 430,000 people to lose their health insurance, according to an analysis from the Brookings Institution.

Those with slightly higher incomes pay for part of their premiums already, but the amount would increase dramatically if the enhanced credits expire. For people who make 250 percent of the federal poverty level ($53,000 for a couple in 2025), costs would go from about 4 percent to 8 percent of their income.

About a million people would go from paying 8 percent of their income on health insurance premiums to becoming responsible for the entire cost themselves. That would be especially painful because health insurance premiums are expected to increase by 18 percent in 2026. For lower- and middle-income people whose costs are capped at a particular share of their income, that doesn’t make a difference. But those who are no longer covered by the credit are responsible for the full cost of their premiums — including those increases.

If the tax credits do expire, the Urban Institute estimates that about a third of the people who benefit from the enhanced premium tax credit will lose those subsidies entirely. Of those, 4.8 million will become uninsured, and the rest will achieve health coverage some other way: perhaps switching to a spouse’s insurance, or leaving their job at a small business to find an employer that will offer health insurance.

“The marketplaces themselves are going to become smaller,” said Banthin. “In some states, they’ll be half the size. And so the people who stay enrolled are going to have fewer choices.”

Those who remain will have to either shoulder higher costs or switch to a lower level of coverage. These increasing costs will probably come as a surprise to many people who benefit from the enhanced tax credit. A poll conducted a week before the government shutdown found that more than half of people who purchased insurance through the marketplaces said they had heard little or nothing about the expiring tax credits.

According to Cox, that’s because the tax credits usually operate as a discount at the time of purchase — and the marketplaces don’t advertise why the prices are lower or what they would be without the enhanced premium tax credits. Anyone who purchased a plan for the first time after the enhanced credits went into effect might not even be aware that prices used to be higher.