The White House and Republicans in Congress have doubled down on their 15-year fight to destroy the Affordable Care Act (ACA). The so-called “One Big Beautiful Bill Act” (OBBBA) and regulations pushed out by the Trump Administration this spring will already make health insurance on the individual market more expensive and harder to get. Now, the enhanced premium tax credits (ePTCs) that have made health insurance more affordable for low- and middle-income people since 2021 are set to expire at the end of the year. The Congressional Budget Office estimates that if Congress allows ePTCs to expire, 4.2 million people will become uninsured by 2034, on top of the 10 million expected to lose coverage under OBBBA. These attacks on the ACA represent a coordinated threat that will strip health care from millions of Americans unless Congress reverses course and acts now.
Since the ACA was implemented in 2014, households between 100-400% of the Federal Poverty Level (FPL) have been eligible for income-based PTCs to lower the cost of Marketplace plans. Most people elect to receive PTCs on an “advanced” basis (APTCs), reducing monthly premium costs automatically throughout the year. Recognizing the importance of affordable health coverage as part of its response to the COVID-19 pandemic, Congress enhanced the original PTCs in 2021 by removing the 400% eligibility ceiling and making subsidies more generous. Marketplace enrollment has doubled since ePTCs were established, with over 24 million people around the country enrolling in coverage during Open Enrollment last year. Nationally, 92% of 2025 enrollees receive APTCs, with an average premium cost of $113 after PTCs compared to the $619 average cost before APTCs are applied.
If current tax credit rules expire, the clock will turn back to former affordability standards and 2026 Marketplace premium costs would skyrocket. With PTCs reverting to pre-2021 levels, the average household would pay 75% more for its premiums in 2026 than it did in 2025. Low-income households could pay double, triple, or more for the same coverage they have this year. Individuals with incomes above 400% FPL would lose access to all PTCs, not just ePTCs.
People shopping for 2026 coverage in November and December of this year will be confronted with tough choices about how and whether they can absorb much higher premiums while also grappling with inflation and rising housing costs. Some people will be forced to cut other areas of their household budget to cover higher premium costs. Others will opt for a less-generous plans with higher cost-sharing, which discourages people from seeking timely care. And still others will be forced to drop coverage entirely.
The first households to drop coverage are likely to be those whose members are relatively healthy. As a result, the pool of people covered by Marketplace policies will shrink and, on average, become sicker and more expensive to cover. Insurance companies will respond by pushing premiums even higher in the years to come – forcing more and more people to drop coverage over time until the market is no longer sustainable. Those familiar with the pre-ACA coverage landscape will remember the all-too-accurate terminology for this phenomenon: the “death spiral”.
Colorado and Other States Are Sounding the Alarm
We don’t need a crystal ball to know how these changes will affect consumers. The specter of PTC reductions, alongside OBBBA and regulatory changes, have already rattled the insurance industry in some states, driving massive premium increases.
In Colorado, where nearly 300,000 people are enrolled in Marketplace coverage and 80% of enrollees receive financial help, insurers requested an average rate increase of 28.4% over last year (and a stunning 38.5% average increase in rural western areas of the state). In August, two insurers filed paperwork to discontinue multiple plans in the individual market, threating coverage for 96,000 people. Only after the Colorado General Assembly passed stopgap legislation providing $100 million to stabilize the individual market did the insurers reverse course and agree to continue offering plans in all counties they covered in 2025. The state’s Insurance Commissioner has stated that while the infusion of state funding will blunt some of the effects of rising health costs, it does not obviate the need for Congress to extend ePTCs: “If Congress doesn’t extend them, at the beginning of next year, most Coloradans enrolled in the individual market will see their premiums skyrocket and tens of thousands of Coloradans will lose coverage. If Congress doesn’t act, the pain will be unspeakable.”
Sharply increased premium prices combined with reduced subsidies would be a double whammy for households shopping for coverage this fall. As noted by KFF, for example:
- A family of four in Denver making 250% FPL ($80,375) is currently required to pay 4% of their income towards the cost of their health insurance premiums. After premium tax credits, they pay about $268 per month for a mid-level plan in 2025. If ePTCs expire, they will be required to pay more than 8% of their income and their monthly health insurance bill will more than double to $565 for the same type of plan.
- A single, 62-year old adult in Elbert County, Colorado with an income of 175% FPL ($27,387.50) pays 1% of her income for a monthly premium cost of about $23 per month for a silver plan. The same type of plan will cost her more than five times as much on average, about $123 per month, if Congress lets ePTCs expire.
Colorado is not alone. In Illinois, where individual market rates will increase by an average of 28.8% in 2026, three issuers have announced plans to leave the Marketplace entirely, with another issuer declining to offer plans in Cook County (which includes all of Chicago). In Delaware, state regulators have approved rate increases between 25-35% over this year, and noted that at least one issuer threatened to leave the Marketplace if their requested increase in excess of 31% was not approved. And in New Mexico, although the state pledged $68 million to make up any loss in ePTCs for residents up to 400% FPL, insurance regulators ultimately approved an average 35.7% increase in individual market premiums for 2026.
Congress Must Act Now to Protect Access to Health Coverage
The pain of market collapse will not be spread equally. Medicaid non-expansion states saw the greatest increase in coverage levels following the expansion of PTCs in 2021. Unsurprisingly, these states would experience the greatest coverage losses if PTC levels are reduced. And as Colorado’s current experience already proves, rural and frontier areas that already have higher medical costs and less issuer competition may experience some of the highest premium increases. In August, state insurance commissioners wrote to leaders in Congress, emphasizing that the expiration of ePTCs would disproportionately harm enrollees over 55. In combination with OBBBA’s targeted attacks on Medicaid, it is clear that access to affordable, comprehensive health coverage is under threat.
But it’s not too late. Congress can act before the end of the year to stem the tide of coverage losses by making ePTCs permanent at current levels. With Congress back on Capitol Hill after summer recess, opponents of affordable health coverage are ramping up negative PR, claiming that health care tax credits are nothing more than “COVID credits” or giveaways to “phantom enrollees”. Others appear eager to play politics at the expense of millions whose health insurance hangs in the balance, proposing a one-year delay to push ePTC expiration until just after next year’s mid-term election. But these rhetorical attacks and political sleight-of-hand are just ugly games in service of a longstanding movement to take down the ACA. The people whose coverage hangs in the balance are all too real. And Congress is running out of time to preserve their health care.
