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4.8M lose coverage with expired enhanced premium tax credits

Allowing Marketplace enhanced premium tax credits would affect health insurance affordability for millions.

Sara Heath
By
Published: 22 Sep 2025

Subsidized health insurance coverage hangs in the balance for 7.3 million people if Congress does not extend the premium tax credits available on the Affordable Care Act Marketplaces, according to an assessment from the Urban Institute, supported by the Commonwealth Fund.

Additionally, 4.8 million people stand to lose health insurance coverage all together should the premium tax credits (PTCs), set to expire at the end of 2025, not be extended.

"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," the Urban Institute authors explained. "As a result, Marketplace enrollment steadily increased, reaching a new high of over 24 million plan selections for 2025."

The progress made by the premium PTCs is set to be undone should Congress allow them to sunset at the end of this year, the Urban Institute added. Taking into considering the effect of the PTCs, plus new Marketplace provisions included in the One Big Beautiful Bill Act, the researchers estimated serious affordability problems that will ultimately lead to loss of coverage for some individuals.

Inaction on enhanced PTCs imperils affordable coverage

Foremost, elimination of the enhanced PTCs would end subsidized Marketplace coverage in 2026 for 7.3 million people. This means these individuals would be paying more for their Marketplace coverage, potentially causing serious financial strain.

In Georgia, Louisiana, Mississippi, Oregon, South Carolina, Tennessee, Texas and West Virginia, subsidized Marketplace enrollment would fall by more than half.

There would also be serious affordability issues at play, Urban Institute added. For folks with subsidized Marketplace coverage and incomes below 250% of the federal poverty level (FPL), average net premiums would increase to $919. That is more than four times higher than the $169 premiums seen with the enhanced PTCs. That totals $80,375 for a family of four, Urban added.

For folks earning between 250% and 400% of FPL, net premiums would more than double from $1,171 to $2,455. That shakes out to $80,375 to $128,600 for a family of four in this income bracket.

Finally, for folks with incomes above 400% of FPL, net premiums would rise from $4,436 to $8,471, or $128,600 for a family of four.

Ultimately, inaction on enhanced PTCs would result in 4.8 million more people being uninsured compared to if PTCs were extended, the Urban Institute said. That would be a 21% increase in the uninsured population, with non-Hispanic Black people, non-Hispanic White people and young adults being the most likely to be impacted.

"Enhanced PTCs result in lower premiums for Marketplace consumers at all income levels and set zero-cost premiums for many low-income consumers," the researchers concluded.

"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."

Sara Heath has reported news related to patient engagement and health equity since 2015.

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