Millions of Americans may face steep health insurance premium increases next year if the enhanced Affordable Care Act (ACA) premium tax credits expire as scheduled at the end of this year. States that voted mostly for President Donald Trump in the 2024 election are expected to see some of the largest projected jumps.
Why it matters
The enhanced subsidies lower monthly premiums for marketplace enrollees across a wide range of incomes. If they lapse, many people could see large increases in what they pay—unless Congress passes an extension. The Congressional Budget Office has warned that ending the enhanced credits could more than double premiums for many enrollees next year and push roughly 2 million more people into being uninsured.
What to know
The ACA marketplace, created in 2010, offers coverage to people who don’t qualify for Medicaid and don’t receive insurance through an employer. In 2020, Congress expanded premium support through the Enhanced Premium Tax Credit to help consumers manage costs during the COVID-19 pandemic. Those larger subsidies cut premiums substantially—and for some lower-income enrollees, brought monthly premiums down to $0.
KFF Health data shows wide variation by state. For a 60-year-old earning 401 percent of the federal poverty level ($62,757 per year) buying a Benchmark Silver Plan without the enhanced tax credits, the ten states with the highest average annual premium payments are projected to be:
- Wyoming — $22,452 per year — (Trump)
- West Virginia — $22,008 — (Trump)
- Alaska — $19,632 — (Trump)
- Connecticut — $16,836 — (Kamala Harris)
- Arkansas — $14,388 — (Trump)
- Tennessee — $12,780 — (Trump)
- Nebraska — $12,768 — (Trump)
- Maine — $12,732 — (Harris)
- Montana — $12,300 — (Trump)
- Delaware — $12,276 — (Harris)
Seven of these ten states voted for Trump in 2024, while three backed Kamala Harris. More broadly, about 76 percent (18) of the top 25 states projected to have the highest premiums voted for Trump.
On the other end of the range, the states with the lowest projected annual premium payments are:
- Rhode Island — $7,572 — (Harris)
- Iowa — $7,428 — (Trump)
- Nevada — $7,332 — (Trump)
- Idaho — $7,152 — (Trump)
- Indiana — $6,732 — (Trump)
- Virginia — $6,252 — (Harris)
- Minnesota — $6,084 — (Harris)
- New Hampshire — $4,872 — (Harris)
- Massachusetts — $4,728 — (Harris)
- New York — $4,464 — (Harris)
Here, the political split is even: five states voted for Trump and five for Harris.
Why some states face bigger jumps
Professor Stacey B. Lee, a Johns Hopkins University professor and CEO of Praxis Pacisci, said the states projected to see the highest premiums tend to share structural challenges: limited insurer competition, older and smaller populations, higher provider prices, and geographic barriers that raise the cost of delivering care.
“In these markets, the gross premiums, meaning the price before subsidies, can exceed $30,000 a year for a 60-year-old,” she said. She added that the enhanced credits didn’t just reduce premiums—in many places, they made coverage workable for middle-income residents.
Lee also pointed to differences in how states entered the ACA era. States such as New York, Massachusetts, and New Hampshire, she said, already had rules and oversight that helped stabilize their individual insurance markets, including community rating, guaranteed issue, and stronger market supervision. As a result, their pricing was more predictable even before the larger federal subsidies.
Where Congress stands
Lawmakers have not reached a deal to extend the enhanced subsidies as part of a broader health care package. Democrats have pushed to keep the credits in place, and in October many opposed a federal spending bill that did not include an extension. Republicans declined to add the subsidies, and the standoff ultimately triggered a 43-day government shutdown, the longest in U.S. history.
Weeks later, after Republicans agreed to allow a vote on an extension, the Senate failed to pass two competing health care bills. One Democratic-backed measure would have extended the enhanced subsidies for three years.
This week, four Republicans joined Democrats in signing a discharge petition aimed at forcing a vote on that three-year extension. The effort failed when the House voted 204–203 to block an expedited vote. When the vote was gaveled closed by House Republican leadership, 26 members had not yet cast ballots, with some still attempting to do so—an unusual but not unprecedented move in a tight vote.
