Millions of Americans who relied on enhanced federal subsidies to afford health insurance through the Affordable Care Act marketplace are now facing sharply higher premiums or outright loss of coverage — a slow-moving public health crisis that policy experts say could leave more than four million people uninsured by the end of 2026.
The enhanced premium tax credits, which had dramatically reduced the cost of marketplace coverage since 2021 and driven record enrollment, expired at the end of 2025. The One Big Beautiful Bill Act, signed into law in July 2025, did not extend them. For tens of millions of marketplace enrollees, the first sign was a premium bill in January 2026 that looked nothing like last year's.
How Many People Are Affected — and Where
The scale of projected coverage loss is significant. The Congressional Budget Office projects the number of uninsured Americans will increase by 3.4 million in 2026 compared to 2025, with even larger increases projected in 2027 and 2028. Independent analyses offer higher projections: the Economic Security Project forecasts 4.2 million people will lose coverage, while the Urban Institute and Commonwealth Fund project 4.8 million people will become uninsured in 2026 alone.
The Center on Budget and Policy Priorities notes that the loss of enhanced tax credits is expected to cause the average annual premium for marketplace enrollees to roughly double — from approximately $888 per year to $1,904 per year — an increase of 114%. For most low- and moderate-income earners, that jump is simply unaffordable.
The communities facing the greatest risk are low-income working adults in states that did not expand Medicaid. In states like Texas, Florida, Georgia, Tennessee, and others without Medicaid expansion, adults earning just above the poverty line have no fallback coverage option — they earn too much for Medicaid and now face marketplace premiums they cannot afford.
| Projection Source | Estimated People Losing ACA Marketplace Coverage in 2026 |
| Congressional Budget Office (CBO) | 3.4–3.8 million uninsured |
| Economic Security Project | 4.2 million |
| Urban Institute / Commonwealth Fund | 4.8 million |
| Average premium increase for enrollees | +114% (approx. $888 to $1,904/year) |
| Medicaid coverage projected lost (OBBBA) | 11.8 million |
| Combined projected coverage loss (ACA + Medicaid) | 15+ million Americans |
| States most at risk | Non-Medicaid expansion states (TX, FL, GA, TN, and others) |
What the Numbers Actually Mean for Health Outcomes
Health coverage is not an abstract policy metric. Uninsured Americans delay or skip preventive care, avoid filling prescriptions, and are more likely to show up in emergency rooms with conditions that could have been caught earlier and treated at far lower cost. Research consistently links coverage loss to worse health outcomes, particularly for people managing chronic conditions such as diabetes, hypertension, asthma, and heart disease.
The American Medical Association has projected that if enhanced credits are not restored and Medicaid cuts take full effect, approximately 10 million people could lose health insurance coverage by 2034. The AMA's Board Chair has called the One Big Beautiful Bill Act a significant setback for coverage access.
"Lower measles vaccination rates are a key driver for outbreaks like the ones we're seeing across many states this year," said KFF's Josh Michaud — a reminder that vaccination rates and health coverage are interconnected: when people lose insurance, preventive care, including vaccinations, drops alongside it.
The coverage gap also affects hospitals directly. When more patients are uninsured, hospitals absorb higher levels of uncompensated care — a financial pressure that falls hardest on safety-net hospitals and rural facilities, which often operate on thin margins even in the best of times.
Are There Any Options Left for People Losing Coverage?
For people who lose marketplace coverage due to a qualifying life event — including losing eligibility for a tax credit — a Special Enrollment Period may be available through HealthCare.gov. However, if the premium increase alone drives someone to voluntarily drop coverage without a qualifying event, they may have limited options until the next open enrollment period.
Medicaid and the Children's Health Insurance Program (CHIP) remain available for those who qualify. State-run programs and federally qualified health centers can provide lower-cost care for the uninsured. The Health Resources & Services Administration operates a searchable database of health centers offering sliding-scale fee services.
The political prospect for restoring the enhanced credits is currently unclear. The One Big Beautiful Bill Act did not include an extension, and no legislative vehicle for restoration has been identified as of mid-June 2026. Health policy advocates have urged Congress to act, noting that the human and fiscal costs of widespread uninsurance far exceed the approximately $31 billion the CBO estimated it would cost to restore the credits.
What the Policy Debate Is Missing
Coverage statistics measure people who enroll — they don't measure people who forgo needed care quietly, without generating a data point. The public health consequences of millions of Americans going without insurance tend to surface slowly: in rising rates of late-stage disease diagnoses, in overcrowded emergency departments, and in years of population health data that arrive too late to prevent the harm.
For state and local health departments already operating under strained budgets, the prospect of a large and rapid increase in uninsured residents is a planning challenge with no simple solution. Local officials, hospitals, and community health organizations have been given little advanced warning about the specific geographic concentration of coverage losses and limited resources to respond.
Frequently Asked Questions
What are the enhanced ACA premium tax credits?
These were boosted subsidies introduced in 2021 that significantly reduced the monthly premium cost for people buying health insurance on the ACA marketplace. They allowed many people who previously couldn't afford marketplace plans to enroll. They expired at the end of 2025 without Congressional extension.
How do I know if I lost my subsidy?
If your monthly marketplace premium increased significantly in January 2026 or your insurer notified you of a change in your subsidy amount, you may have been affected. Log in to HealthCare.gov or your state marketplace account to review your current subsidy status.
Who is most at risk of losing coverage?
Low- and moderate-income adults who earn too much for Medicaid but rely on enhanced subsidies to afford marketplace plans — particularly in the 10 states that have not expanded Medicaid, where no safety net exists for adults with incomes just above the poverty level.
What can I do if I can no longer afford marketplace coverage?
Check eligibility for Medicaid or CHIP at your state's health department. Visit a federally qualified health center (searchable at findahealthcenter.hrsa.gov) for sliding-scale care. Contact a licensed insurance navigator through HealthCare.gov for free assistance.
Could Congress restore the subsidies?
Possibly, but no legislative vehicle has been identified as of June 2026. Health advocacy organizations, hospital groups, and physician societies have called for restoration. The CBO has estimated that restoring the enhanced credits permanently would cost approximately $31 billion over 10 years.
