In fact, the heightened premium subsidies in the Affordable Care Act are simply “on life support” as Congress shows no intention of extending them past 2025 when they are set to expire. “The impact of eliminating these subsidies would be striking, making healthcare costs double, potentially wiping out five years of progress in one night.”
More than 22 million people, or 92% of marketplace-insured individuals, depend on this supplementary assistance. Even though all people who are currently in receipt of this assistance are necessarily set to suffer due to the effects of the lack of continued support, there are people who are, by all means, in a position to suffer much more than others when the exclusion of these subsidies comes into effect. The following are the nine categories of people who are in a position to suffer most when the exclusion of the subsidy comes into effect.
1. Middle-Income Families at the Subsidy Cliff
A return to the “subsidy cliff” will be an extremely difficult transition for those currently slightly above 400 percent of the federal poverty levels, an estimated 63,000 individuals per year or 129,000 for a family of four in the year 2025. Currently, their premium expenses are capped at 8.5 percent of income, but they will have to foot the bill at market rates without the bonus subsidies. Urban Institute estimates indicate that the average annual premium rates for this group will go up from 4,400 per year to 8,500 per year by 2026.
Those just above them will be impacted the most since they will be charged the same unsubsidized rates as those earning more money but fewer dollars to pay for their insurance. Approximately 725,000 individuals fall between the 400% and 500% levels of poverty, while 1.8 million are soon to follow in the 300% and 400% levels of poverty. For them, this means choosing between insurance and their basic needs being addressed.
2. Early Retirees and Age-Related Rate Increases
Individuals aged between 55 and 64 who retire before they can benefit from Medicare are highly dependent on the ACA plans. In the year 2025, 24% of the enrollments in the marketplace fall in this bracket. The rates are allowed to be set maximum three times as high as in the case of younger individuals.
Without these benefits, a senior at 60 with an income of $64,000, if over the cliff, will see their premiums escalate drastically from $6,200 currently being paid to nearly $14,900, resulting in well over 23% of their income going towards these expenses.
3. Smaller Business Owners & the Self-Employed
Almost 40 percent of adults aged 18 to 64 with marketplace coverage have a connection to small businesses as owners of these businesses or as workers in those businesses that employ fewer than 25 people. These people most likely use ACA affordability provisions since large employers offer health benefits more often.
Some industries are very market-dependent: 34% of chiropractors, 28% of real estate brokers, and 27% of farmers and ranchers rely on the market for insurance. “Approximately 5 million small businesses and self-employed individuals will be covered in 2025,” according to Treasury Department data. “It would be impossible for them to foot the bill themselves without subsidies,” said Benjamin Kweskin.
4. Black Americans at Risk of Coverage Reversal
The Black enrollment in the marketplace increased by 95% from 2020 to 2023, according to the data from ASPE. In the large metropolitan areas of Atlanta, Houston, Dallas, and Miami, over 170,000 black Americans could lose coverage by 2026 if the expiration of subsidies materializes. According to the Economic Policy Institute, this would translate to more than 200 preventable black deaths annually because of the failure to get medical services on time.
There would be a cost associated, as it states: “African American families would see a premium rate increase of $740 million per year,” and then lost spending could reach as high as “$1.9 billion in the local economy as families from other income levels switch salaries to pay premiums.” There is another cost associated with the disparity between the white and black wealth-gap issues, as it states: “The average net worth of African American families is $27,100 versus $250,400 for white families.”
5. Latino Communities at Risk of Uninsurance
The Latino market enrolled at 18% of all people enrolled in 2020 and grew to 22% by 2025. Latino communities living in Southern states would likely see a dramatic reversal of the progress they have made if the elimination of the expanded subsidies occurs.
Indeed, the majority of Latino families reside in Medicaid-expansion-denying states and thus rely on subsidies under the ACA. According to an alert by the Bipartisan Policy Center, most of these families could lose their benefits once the expiration of the ACA subsidies occurs.
6. Citizens of States that Voted for Trump in the 2024 Election
The states carried by President Trump in 2024 contain 88% of the total enrollment increase under the Affordable Care Act since 2020. The total sign-ups in these states are up an average of 157%, compared with an increase of 36% for states won by Sen. Kamala Harris. In six additional states, including Texas, Mississippi, West Virginia, Louisiana, Georgia, and Tennessee, there’s been an increase of more than three times.
These states also get the most subsidy payments. Beneficiaries in Florida have received 31.7 billion dollars in 2025 in premium tax credits, and in Texas, 24.1 billion dollars in 2025, making a total of 39 percent of national share in all. The lack of subsidies will hit this region most.
7. Rural Populations Dependent Upon Marketplace Savings
About 3.1 million marketplace enrollees in 2025 lived in rural areas, where there is a greater increase in the cost of premiums as well as a reduced network of providers. A greater sum of money in rural markets was saved through the increased subsidy by an average of 890 dollars a year, which is 28% more than city residents.
Loss of subsidies means that there may be a 37% drop in those who are covered in certain states that are considered rural. This may drop by 30% because of loss of coverage. Increases in premium costs may range from 760 dollars to 3,000 dollars and above per person per month.
8. Low-Income Families Losing $0 Premium Plans
Through higher subsidies, individuals up to 150 percent of poverty, or about $23,000 a year in 2025, would be eligible for benchmark silver plans with a premium cost of $0. Nearly 45 percent of those eligible for market-based plans would fall into this income category. Without improvements, a premium could cost 4 percent of income or $1,607 a year for a family of four at 140 percent of poverty.
Those living a paycheck-to-paycheck lifestyle could find that a minimal increase in expenses could mean a decrease in benefits. Those in a Non-Expansion State could have a loss of benefits at 100%-138% of poverty and not be able to have access to Medicaid benefits either and could be left in a ‘dangerous gap.’
9. Seniors in High-Premium States
Seniors will feel the pain of premium increases in states where the cost of care is high initially. Let’s consider an example. A 60-year-old couple from West Virginia with an income of $85,000 will have to shell out over half a million dollars annually for a typical ‘silver’ group health insurance plan, which at present would cost them approximately $7,225. These states will have fewer insurance companies and minimal competition. This is going to be expensive for seniors because they will have to shell out premium charges that would mean they will spend at least one-fourth or rather more of their income for health insurance.
“The looming expiration of these enhanced subsidies is not simply a footnote in a budget bill; it is, in fact, a seismic shift in health care policy.” Indeed, it is true that millions will be directly and adversely affected; it is also true that they will most probably be facing challenges like economic insecurity in general, and health disparities related to race and lack of insurance choices, per se. If Congress does not address this situation immediately, it will lead to reversal of nearly nine years’ hard work and progress achieved in increasing health insurance coverage for millions of people with an inevitable rise in health disparities related to income and lack of insurance choices for people who will be priced out of health care access.
