To help more Americans access health care during the COVID-19 pandemic, Congress substantially increased the subsidies available to buy health insurance through enhanced premium tax credits (PTCs). These expanded benefits were enacted as part of the American Rescue Plan Act in March 2021 and extended through 2025 as part of the 2022 Inflation Reduction Act. With the end of these subsidies on the horizon, federal, state, and local policymakers must consider the expiration’s potential to cause another crisis in health care access and affordability.
By our analysis, if PTC enhancements expire after 2025, subsidized Marketplace enrollment would decline by 7.2 million people, and 4.0 million people would become uninsured. However, these effects aren’t felt equally across states or by race, income, and age, which means some communities may experience greater coverage losses, making health care unaffordable and inaccessible. To explore these effects by state, we produced an interactive tool displaying effects on health insurance coverage in each state by age, income, race, and ethnicity.
The expiration of enhanced PTCs has varied effects by state
When Congress passed the enhanced PTCs in March 2021, it made health insurance more accessible across three dimensions: it substantially increased the subsidies available to buy insurance in the Marketplace, it extended eligibility for PTCs to people with incomes above 400 percent of the federal poverty level (FPL), and it ensured that enrollees with incomes between 100 and 150 percent of FPL could get coverage without having to pay premiums. Since then, Marketplace plan selections have risen from 12.0 million to 21.4 million in 2024.
These benefits’ expiration risks dramatic declines in Marketplace coverage and increases in uninsurance, but these effects vary widely by individual states. In Louisiana, Kentucky, and Texas, subsidized Marketplace coverage would decline by more than 60 percent. Because Texas is a large state, its decline of 1.8 million enrollees would be more than a quarter of the national change. Hawaii, Maine, and Massachusetts, however, would see smaller declines of less than 15 percent.
Increases in uninsurance would also vary by state, with Mississippi experiencing a 41 percent increase in uninsurance (112,000 people), and Tennessee and South Carolina seeing increases of more than 33 percent. Other states would have far smaller uninsurance increases, with Hawaii; Washington, DC; New York; and New Mexico all expecting increases of less than 2 percent.
States without expanded Medicaid would see the largest effects
One decision explaining these varied effects is the adoption or nonadoption of expanded Medicaid made available through the Affordable Care Act as of 2014. To date, 10 states—Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming—haven’t expanded Medicaid eligibility, which would allow people with incomes below 138 percent of FPL to enroll in Medicaid. Without expansion, these people may enroll in Marketplace coverage with PTCs if they have incomes of 100 percent of FPL or more, an option that would be jeopardized for many if enhanced PTCs expired.
Without enhanced PTCs, nonexpansion states would see larger percentage declines than most other states. Although the 10 nonexpansion states account for just 28 percent of the nation’s under-65 population, they would account for 63 percent of the enrollment decline in subsidized Marketplace plans (4.5 million people) if enhanced PTCs expire.
The remaining 41 states (including Washington, DC) that expanded Medicaid account for 72 percent of the nation’s under-65 population but just 37 percent of the enrollment decline in subsidized Marketplace plans (2.7 million people).
For both expansion and nonexpansion states, our estimates reflect recent changes in Marketplace enrollment in each state. States with the largest increases since 2021 would see the largest declines in enrollment without enhanced PTCs.
Nonexpansion states also would see some of the largest percentage increases in uninsured people. If the PTCs expire, the number of people without health insurance would increase by 2.5 million people in nonexpansion states compared with an increase of 1.5 million people in expansion states.
Black and Hispanic people would see disproportionate decreases in health insurance coverage
Without enhanced PTCs, 1.1 million Black people would lose subsidized Marketplace coverage, about 75 percent of whom live in nonexpansion states. Similarly, 1.3 million Hispanic people would lose subsidized Marketplace coverage, about 75 percent of whom live in nonexpansion states. Comparatively, just over half of the 4.3 million white people who would lose subsidized Marketplace plans live in nonexpansion states.
The changes in uninsurance tell a similar story. Three out of every 4 of the 760,000 Black people who would become uninsured live in nonexpansion states, as do 3 out of 4 of the 970,000 Hispanic people who would become uninsured. Again, just over half of the 2 million white people who would become uninsured live in nonexpansion states.
For Black or Hispanic people living in nonexpansion states, the uninsurance rate would increase by 4.2 percentage points compared with 2.6 percentage points among white people. In expansion states, we project the expiration of enhanced PTCs would have a limited effect on uninsurance rates by race and ethnicity.
Younger and middle-aged adults would leave the Marketplace
Finally, younger adults between ages 19 and 34 and middle-aged adults between 35 and 54 account for the largest numbers of people leaving the Marketplace or becoming uninsured. This trend could cause long-term issues, as enrolling younger adults in Marketplace plans helps maintain premium affordability and stability for everyone else.
Changes in coverage among older adults between 55 and 64 years are smaller, in part because this group is more likely to have more health care needs and a greater willingness to pay for coverage despite a reduction in PTCs. At the other end, children are less affected by the expiration because they are less likely to be enrolled in the Marketplace plans because they’re often eligible for Medicaid or the Children’s Health Insurance Program.
Enhanced PTCs expiration could cause 4 million people to lose health insurance
If Congress doesn’t extend enhanced PTCs after 2025, millions of people would leave the Marketplace, and millions would become uninsured. These effects are likely to be concentrated among communities who already experience less access to health insurance, including Black and Hispanic communities and people in states that haven’t adopted expanded Medicaid eligibility. Without affordable health insurance, these families will lack the resources needed to respond to health emergencies and support their daily health and well-being.
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