On Dec. 31, 2025, the enhanced Affordable Care Act (ACA) premium tax credits expired without congressional renewal — and the consequences are already showing up in revenue mix reports, emergency department volumes, and the growing lines at community health centers and human services organizations.
Since the introduction of the tax credits in 2021, enrollment in the ACA Marketplace more than doubled — from about 11 million to over 24 million people — the vast majority of whom received an enhanced premium tax credit. That progress is now reversing: the federal government’s own 2026 Open Enrollment Report confirms 1.2 million fewer consumers signed up for coverage — a 5 percent national decline — with new enrollment falling 13 percent.
The expiration more than doubled what subsidized enrollees pay in premiums annually — a 114 percent increase, from an average of $888 in 2025 to $1,904 in 2026. For the populations health and human services organizations serve, a $1,000-plus annual premium increase isn’t a budget inconvenience — it’s a coverage-ending event.
A March 2026 KFF poll confirms exactly that: 9 percent of those who were enrolled in ACA Marketplace plans last year are now uninsured, and an additional 17 percent say they are not confident they can afford their new premiums. Among those who kept their coverage, 55 percent have cut or plan to cut spending on basic household expenses, like food and clothing, to afford their premiums.
The State-Level Picture: A Warning System Already Flashing
North Carolinaposted the largest enrollment decline of any state in the country — 761,457 enrolled for 2026, a 22 percent drop of 214,000 people. A nearly 30 percent premium rate hike compounded the subsidy loss, and North Carolina’s navigator grant was slashed 90 percent to $750,000. Those consumers are already showing up at community health centers, local health departments, and human services providers.
Washington Stateillustrates how directly the tax credit expiration translates into coverage loss. About 19,000 fewer Washingtonians enrolled in marketplace coverage in 2026, and more than 28,000 customers canceled their plans outright — the highest cancellation count in any prior year. Premiums on the Washington Health Benefit Exchange rose an average of 21 percent. The state deployed its Cascade Care Savings program to soften the blow, helping more than 118,000 enrollees. Rural counties bore the sharpest impact — a preview of the geography of harm that providers across the country are already navigating.
Connecticut saw the stakes up close: of the roughly 143,000 Access Health CT enrollees receiving subsidies, nearly 32,000 lost their financial assistance entirely when the enhanced credits expired, with the remainder seeing reduced support — translating to an average premium increase of $2,380 per year per enrollee. Gov. Lamont deployed $70 million in emergency funds to partially offset the gap — but explicitly called it a one-year fix at a cost of $295 million annually.
What This Means for the Bottom Line
This isn’t only a coverage access issue. It is a provider financial stability issue. Research from the Urban Institute and the Robert Wood Johnson Foundation (RWJF) is blunt: hospitals, physicians, and other providers face more than $32.1 billion in lost revenue in 2026, alongside a $7.7 billion spike in uncompensated care.
For rural providers and safety-net organizations, the math is especially unforgiving: across 1,730 rural hospitals, net patient revenues are estimated to decline by $1.6 billion, uncompensated care costs would increase by more than 10 percent, and operating margins would decline by nearly 10 percent. Economic modeling projects nearly 340,000 health care sector jobs will be lost in 2026 alone.
The Broader Legislative Assault on Funding Infrastructure
The tax credit expiration is not occurring in isolation. The “One Big Beautiful Bill Act” (OBBBA) represents the largest single reduction in Medicaid funding in the program’s 60-year history. The OBBBA will increase the total number of uninsured Americans by 10 million by 2034 — 7.5 million from Medicaid and CHIP cuts, and 2.1 million from Marketplace changes. That figure does not include the additional 4.2 million people projected to lose coverage due to the expiration of the enhanced premium tax credit, which was already assumed in the CBO baseline. A KFF analysis combining both effects estimates a total increase of roughly 14 million to 16 million uninsured by 2034.
The policy mechanisms driving these losses deserve close attention. Starting Dec. 31, 2026, states must conduct Medicaid eligibility checks every six months instead of annually. Beginning in January 2027, most will need to document 80 hours of monthly work or qualifying activities to keep coverage. The CBO projects work reporting requirements alone will increase the number of uninsured by 4.8 million by 2034 — not because those people are ineligible, but because they cannot navigate the paperwork. Each represents a patient who may arrive without coverage or delay care until a crisis.
What Leaders Must Do Now
The organizations that will weather this storm are those that act now, before coverage losses compound into capacity crises. The ACA Marketplace disruption is not a future risk — it is a present reality showing up in uncompensated care volumes, revenue projections, and client caseloads today. The common thread across all sectors is urgency:
- Healthcare providers need to model the revenue impact of a growing uninsured and underinsured patient population now — updating payer-mix projections, stress-testing operating margins against rising uncompensated care, and identifying which service lines are most exposed
- Human services organizations need to proactively connect clients to remaining coverage options — including residual ACA subsidies, state-based programs, Medicaid for those who qualify, and community health centers — before more people delay care until a crisis forces an emergency room visit
- Government agencies and state health officials still have meaningful discretion — in navigator funding levels, state supplement programs, reinsurance mechanisms, and outreach investments — that will directly shape how many residents fall through the coverage gaps the federal government has created
- Philanthropic foundations should prioritize flexible, rapid-response funding for community health centers, navigator networks, and safety-net providers absorbing the surge of newly uninsured patients — recognizing that the federal investment gap will not self-correct
- Advocacy organizations must shape the federal comment record when the interim final rule is published and influence state-level definitions.
The scale of what is happening is unprecedented. But so is the opportunity for leaders within the health and human service sector to make their case clearly, collectively, and with the gravity this moment demands.