Enhanced premium tax credits (PTCs) were a key element of the American Rescue Plan Act passed by Congress in March 2021 and were extended through 2025 under the Inflation Reduction Act of 2022. The enhanced PTCs substantially increased the subsidies available for people to buy insurance in the Marketplace: they reduced net premiums to zero for some people with low incomes and made subsidies available to people with higher incomes for the first time. As a result, Marketplace enrollment steadily increased, reaching a new high of over 24 million plan selections for 2025.

In this brief, we estimate the impact on coverage of the expiration of enhanced PTCs that would occur in 2026 without action by Congress. Our estimates include the major Marketplace provisions of the One Big Beautiful Bill Act (OBBBA) that will be in effect for 2026 (most will be implemented later) and the provisions of the Marketplace Integrity and Affordability rule released by the Center for Medicare and Medicaid Services (CMS) that will be in effect for 2026, excluding those provisions stayed because of an August 22 decision by a Maryland District Court.

Why This Matters

Congress will debate whether to extend enhanced PTCs again or possibly make them permanent. Since the enhanced PTCs were first enacted in 2021, they have led to record-high enrollment in the Marketplaces at all income levels. Enhanced PTCs result in lower premiums for Marketplace consumers at all income levels and set zero-cost premiums for many low-income consumers. Even those not eligible for PTCs see lower premiums with enhanced PTCs because the additional enrollment has improved the nongroup market risk pool. If Congress does not extend enhanced PTCs after 2025, we project that these gains will be reversed, and 4.8 million people will become uninsured.

What We Found

• We project that 7.3 million fewer people will receive subsidized Marketplace coverage in 2026 if PTCs revert to their standard levels than if enhanced PTCs are extended. Eight states, Georgia, Louisiana, Mississippi, Oregon, South Carolina, Tennessee, Texas, and West Virginia, would see their subsidized Marketplace enrollment fall by more than half.
• Without enhanced PTCs, we project that 4.8 million more people will be uninsured in 2026 relative to a policy that extends enhanced PTCs, an increase in the uninsured population of 21 percent.
  • Non-Hispanic Black people, non-Hispanic White people, and young adults would see the largest increases in uninsurance.
• In 2026, we project that average net premiums, the portion paid by individuals or households after PTCs, will be over four times as large ($919 versus $169) for people with subsidized Marketplace coverage and incomes below 250 percent of the federal poverty level (FPL; 250 percent of FPL is $39,125 for an individual and $80,375 for a family of four) under standard PTCs, compared with a policy of enhanced PTCs.
• Net premiums will more than double, from $1,171 to $2,455, for people with incomes from 250 percent of FPL to 400 percent of FPL.
• Finally, net premiums will nearly double, from $4,436 to $8,471, for people with incomes above 400 percent of FPL who receive subsidized Marketplace coverage under enhanced PTCs, but who would pay the full premium were they to expire.
• These estimates only apply to 2026. Future years will see Marketplace enrollment reductions both with and without enhanced PTCs because of provisions of the OBBBA and CMS Marketplace rules if they eventually take effect.

How We Did It

For this brief, we updated the Health Insurance Policy Simulation Model using 2025 Marketplace premiums and state-level Marketplace enrollment data from the 2025 Open Enrollment Period Report snapshot released by CMS. We adjusted the Open Enrollment Period Report snapshot numbers downward to more accurately represent average monthly Marketplace enrollment for the entire year. These adjustments reflect the “effectuation” of plan choices and midyear attrition. We first calibrated the model to replicate 2025 enrollment with 2025 premiums and Marketplace rules. We then simulated 2026 enrollment and costs in two different ways: (1) assuming enhanced PTCs were extended and remained in effect; and (2) assuming enhanced PTCs expire at the end of 2025 and standard PTCs were back in place. Enrollment for the latter scenario is comparable to enrollment levels before enhanced PTCs and the COVID-era Medicaid continuous coverage requirements were in effect.