News: States facing greatest coverage, funding, job losses with ACA subsidies expired

Enhanced Affordable Care Act (ACA) premium tax credits, which increased subsidy amounts and expanded marketplace eligibility to households earning more than 400% of the federal poverty level, expired on December 31, 2025. With no resolution expected from congressional efforts anytime soon, around 4.8 million people will lose coverage without an extension, the Urban Institute estimated in a report. As of December 23, more than 15.6 million people enrolled in plans on federally run ACA exchanges for 2026 so far, down from 16 million at the same point in 2024, Becker’s Hospital Review reported.

The enhanced subsidies were introduced under the 2021 American Rescue Plan Act, and capped out-of-pocket premiums for a benchmark plan at 8.5% of income. Since taking effect, ACA marketplace enrollment grew to 24.3 million in 2025. The expected growth in uninsured residents in 2026 will affect certain states more than others.

The top five states facing the steepest coverage losses, ranked by estimated growth in uninsured residents are:

1. Mississippi: 65%
2. South Carolina: 50%
3. Tennessee: 41%
4. Texas: 39%
5. Georgia: 39%

Total state gross domestic profits is projected to fall by $34.1 billion and total economic output would decrease by $57 billion, according to a brief from the Commonwealth Fund.

Separate from uninsured status, the top five states facing the largest economic impact (including estimated losses in federal funding) are:

1. Texas
   
   1. Economic output change: −$14.1 billion
   2. Federal funding loss: −$6.3 billion
2. Florida
   
   1. Economic output change: −$9.5 billion
   2. Federal funding loss: −$4.2 billion
3. Georgia
   
   1. Economic output change: −$5.5 billion
   2. Federal funding loss: −$2.5 billion
4. Tennessee
   
   1. Economic output change: −$2.8 billion
   2. Federal funding loss: −$1.3 billion

1. Louisiana
   
   1. Economic output change: −$2.1 billion
   2. Federal funding loss: −$968.6 million

The ripple effects of this expiration will also extend across the healthcare industry. Overall employment is expected to decline by 286,000 jobs in 2026, including 130,000 healthcare positions at hospitals, physician offices, ambulatory care facilities and pharmacies, according to the Commonwealth Fund brief.

The states facing the steepest healthcare job losses are:

1. Texas
   
   1. Healthcare job losses: 30,800
   2. Total jobs lost: 69,300

1. Florida
   
   1. Healthcare job losses: 22,100
   2. Total jobs lost: 49,200
2. Georgia
   
   1. Healthcare job losses: 12,800
   2. Total jobs lost: 28,400
3. Tennessee
   
   1. Healthcare job losses: 5,800
   2. Total jobs lost: 13,300
4. Louisiana
   
   1. Healthcare job losses: 5,200
   2. Total jobs lost: 11,300

Editor’s note: To read Becker’s Hospital Review’s coverage of this story, click here. To read the Urban Institute report, click here. To read the Commonwealth Fund brief, click here.