An Additional 8.2 Million People are Expected to Be Uninsured from Changes in the ACA Marketplaces

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Last week, the Congressional Budget Office (CBO) released new estimates of the impact of the One Big Beautiful Bill Act (OBBA) on the number of people uninsured. CBO projects that the Reconciliation package will increase the number of uninsured by 10.9 million people, 3.1 million of which are expected to become uninsured due to changes in the ACA Marketplaces. On top of that, CBO has estimated that 4.2 million more people will be uninsured due to the expiration of enhanced premium tax credits at the end of this year, and another 900,000 people would be uninsured due to Trump administration proposed ACA Marketplace integrity rules. (Because the OBBA codifies the proposed rule, CBO attributes half of the 1.8 million uninsured resulting from those provisions to the bill and the other half to its projection of baseline spending under current law).

Taking all these factors into account, relative to a scenario where enhanced tax credits are extended and the program integrity rule does not go into effect, these changes in the ACA Marketplaces will lead to an estimated additional 8.2 million people becoming uninsured. Adding in the 7.8 million people who’d become uninsured from changes in Medicaid brings the total to 16 million more uninsured people – about half of which comes from the ACA Marketplace changes.

ACA Marketplace changes are technical and numerous but consequential. Provisions from the proposed Marketplace integrity rule may create additional accessibility barriers to securing Marketplace coverage. For example, new rules will require Marketplace enrollees to verify their income with documentation, rather than self-attestation, in instances where tax data is unavailable. Other provisions in the Reconciliation bill could pose new barriers or increase penalties for people with unpredictable incomes.

The expiration of the enhanced premium tax credits will raise out-of-pocket premium payments for subsidized enrollees by over 75%, on average. Many insurers proposing premiums for 2026 are reporting expectations that the expiration of the enhanced premium tax credits will lead to a sicker enrollee base and drive up the gross premium rates by 4%, on average. The enhanced premium tax credits have led to the ACA markets more than doubling in size, with states won by President Trump seeing much more rapid growth than states won by former Vice President Kamala Harris.

As a share of the population, these ACA Marketplace changes will hit Southern red states the most. In Florida, changes in the ACA Marketplaces will result in an additional 9 percent of the state’s population to become uninsured. Florida has the most ACA Marketplace enrollees out of any state, comprising nearly one-fifth of national enrollment currently. Other states with high shares of their populations becoming uninsured due to changes to the ACA Marketplaces include: Georgia (an additional 6% of the population uninsured due to ACA Marketplace changes), Texas (5%), Mississippi (5%), and South Carolina (4%). This is in addition to coverage losses from Medicaid. Over half of the total 8.2 million increase in the uninsured resulting from changes to the ACA Marketplaces will come from three states: Florida (2.2 million), Texas (1.7 million), and Georgia (690 thousand).

While more attention has been focused on cuts to Medicaid, upcoming changes to the ACA Marketplaces could lead to just as many people losing health insurance coverage.