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This brief describes current state fiscal conditions as states begin fiscal year 2027 budget debates and highlights key areas to watch for Medicaid policy changes as states respond to fiscal challenges and the 2025 reconciliation law.
Take this ten-question quiz to see how much you know about how the ACA affects health insurance coverage and costs as well as who is eligible for financial assistance
President Trump announced a health care framework that leaves open key questions, including those about out-of-pocket costs, premiums, federal spending, and health coverage for people with pre-existing conditions.
After failed Senate votes late last year and no subsequent bipartisan agreement, the enhanced premium tax credits expired as of January 1. Some states, particularly those operating State-Based Marketplaces (SBMs), have been preparing for this possibility for months and are moving to blunt the impact on consumers by implementing their own state-funded subsidies and implementing other programs aimed at stabilizing the cost of unsubsidized premiums.
The ACA's enhanced premium tax credits expired at the end of 2025. This calculator estimates how much out-of-pocket premium payments would increase for families without the enhanced credits. The projected premium increases are estimated based on family income, zip code, size, ages, and 2026 ACA Marketplace premiums.
The amount health insurers charge for coverage on the ACA Marketplaces is rising 26%, on average, in 2026.... Most enrollees would face even sharper increases in what they pay if they ACA’s enhanced premium tax credits expire.
The expiration of the ACA enhanced premium tax credits at the end of this year would reintroduce the “subsidy cliff,” which abruptly ends the credit for Marketplace enrollees earning over 400% of poverty. That means some middle-income enrollees, especially older ones, would spend a much larger share of their income on premium payments than those earning just slightly less with the credit.
Affordable Care Act Marketplace insurers are raising premiums by an average of 18% next year, due in part to the expiring enhanced premium tax credits. Even if the credits are extended in shutdown negotiations, it is unlikely that insurers will have time to revise premiums, though the credits would still offer enrollees relief from them.
Since the enhanced premium tax credits became available in 2021, ACA Marketplace enrollment has increased significantly in some red states, and 57% of enrollees now live in Republican congressional districts.
The ACA enhanced premium tax credits expanded financial assistance to more Marketplace enrollees, an expansion that was especially helpful to older middle-income enrollees, who would see the largest increases in out-of-pocket premiums if the enhanced credits expire.
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