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Republicans gave a roughly $4 trillion tax cut to Americans in the so-called “big beautiful bill” that President Donald Trump signed into law July 4, extending several tax provisions scheduled to expire in 2026. However, there was a notable omission, according to health policy experts: an extension of a tax break that lowered health insurance premiums for millions of people. The enhanced premium tax credits, in place since 2021, have lowered the cost of health insurance premiums for those who buy coverage through the Affordable Care Act marketplace. Enrollees can use these to lower their premium costs upfront or claim the credits at tax time, but the credits are scheduled to expire after 2025. More than 22 million people — about 92% of ACA enrollees — received a federal subsidy this year that reduced their insurance premiums, according to KFF, a nonpartisan health policy research group. Those recipients would see a “sharp premium increase” on Jan. 1, Cynthia Cox, the group’s ACA program director, said during a webinar Wednesday.

Average premiums may rise 75%

The average marketplace enrollee saved $705 in 2024 — a 44% reduction in premium costs — because of the enhanced tax credits, according to a November analysis by the Center on Budget and Policy Priorities, a nonpartisan research and policy institute. Without the credits, average out-of-pocket premiums in 2026 would rise by more than 75%, Larry Levitt, KFF’s executive vice president for health policy, said during the webinar.

The scale of the change to the health-care system is staggering. Larry Levitt KFF’s executive vice president for health policy

Additionally, 4.2 million Americans would become uninsured over the next decade if the enhanced subsidies lapse, according to the nonpartisan Congressional Budget Office. That growth in the ranks of the uninsured is in addition to the nearly 12 million people expected to lose health coverage from over $1 trillion in spending cuts Republicans made to health programs such as Medicaid and the ACA to help offset the legislation’s cost. The spending reduction amounts to the largest rollback of federal health-care support in history, Levitt said. “The scale of the change to the health-care system is staggering,” he said.

How enhanced premium tax credits lowered costs

Premium tax credits were established by the ACA and were originally available for people making between 100% and 400% of the federal poverty level.

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Enhanced credits became available after former President Joe Biden signed the American Rescue Plan, a pandemic-era stimulus package, in 2021. The legislation temporarily increased the amount of the premium tax credit and expanded eligibility to households with an annual income of more than 400% of the federal poverty limit, which was $103,280 for a family of three in 2025, according to The Peterson Center on Healthcare, a nonprofit focused on health care policy, and KFF. The law also capped out-of-pocket premiums for certain plans at 8.5% of income, it said. More from Personal Finance:

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Trump’s ‘big beautiful bill’ slashes CFPB funding Those policies were then extended through 2025 by the Inflation Reduction Act, which Biden signed in 2022.

People who would be affected the most

The enhanced subsidies made insurance more affordable, serving to greatly increase the number of Americans with health insurance, experts said. ACA enrollment has more than doubled, to roughly 24 million people in 2025 from about 11 million in 2020, according to data tracked by The Peterson Center on Healthcare and KFF.

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Proposed federal spending cuts to health care in Republicans’ “One Big Beautiful Bill Act” may increase some families’ medical debts by as much as $22,800, according to a new report from Third Way, a Washington, D.C.-based think tank. The Republican budget bill proposes $1.1 trillion in cuts to health care that target both Medicaid and Affordable Care Act coverage. The Congressional Budget Office, or CBO, a nonpartisan legislative scorekeeper, projected that about 11 million people would lose health-care coverage due to provisions in the bill passed by the House of Representatives if it’s enacted in its current form. The CBO estimated that an additional 4 million or so would lose insurance due to expiring Affordable Care Act subsidies, which the bill doesn’t extend. Another 900,000 would lose coverage due to ACA rule changes the Trump administration proposed this spring. Of the total estimated 16 million who could lose health coverage, that includes 7.8 million individuals on Medicaid and 8.2 million covered through the Affordable Care Act, according to Third Way. Overall, medical debt would increase by $50 billion as a result of the budget bill changes — a 15% rise over today’s $340 billion in unpaid debts, according to Third Way.

‘Medical debt stands in the way of the American Dream’

Health coverage losses would increase the number of people in families with medical debt by 5.4 million, according to Third Way’s report. More than 100 million people currently have medical debt in the U.S., according to KFF. More from Personal Finance:

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Senate tax bill includes $1,000 baby bonus in ‘Trump accounts’ An estimated 2.2 million households would have medical debt because of Medicaid coverage losses, while 3.2 million more people would rack up balances due to Affordable Care Act reforms that may prompt coverage losses or higher premiums, according to Third Way. Without coverage, families may see their medical debts increase by as much as $22,800, according to Third Way’s report. About 87% of households that previously had no medical debt would accumulate an average of $22,800 in balances. Meanwhile, 13% of households may accumulate an additional average of $8,790 in medical debt on top of $13,490 in existing balances. “That’s going to put people’s dreams back, if they’re hoping to go to college or hoping to have a solid retirement or hoping to buy another house,” said David Kendall, senior fellow for health and fiscal policy at Third Way. “Medical debt stands in the way of the American dream, and we shouldn’t make it worse.”

Health insurance ‘makes a measurable difference’

The White House said proposed federal spending cuts are aimed at eliminating “waste, fraud and abuse” in government programs including Medicaid. The Trump administration has said the “big beautiful” bill is a potential “economic windfall for working and middle-class Americans” through tax cuts, higher wages and higher take-home pay. In a Monday letter that cites the Third Way report, Sen. Jeff Merkley, D-Ore., ranking member of the Senate Budget Committee, and Democratic Sens. Cory Booker of New Jersey, Chuck Schumer of New York and Ron Wyden of Oregon, urged Republican leaders to reconsider the proposed health-care cuts.

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U.S. uninsured rates could resurge if Trump’s budget bill passes

toggle caption Lynsey Weatherspoon for KFF Health News

CLARKESVILLE, Ga. — Last September, Alton Fry went to the doctor concerned he had high blood pressure. The trip would result in a prostate cancer diagnosis.

So began the stress of trying to pay for tens of thousands of dollars in treatment — without health insurance.

“I’ve never been sick in my life, so I’ve never needed insurance before,” said Fry, a 54-year-old self-employed masonry contractor who restores old buildings in the rural Appalachian community he’s called home nearly all his life.

Making sure he had insurance was the last thing on his mind, until recently, Fry said. He had been rebuilding his life after a prison stay, maintaining his sobriety, restarting his business, and remarrying his wife. “Things got busy,” he said.

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Now, with a household income of about $48,000, Fry and his wife earn too much to qualify for Georgia’s limited Medicaid expansion. And he said he found that the health plans sold on the state’s Affordable Care Act exchange were too expensive or the coverage too limited.

In late April, a friend launched a crowdfunding campaign to help Fry cover some of the costs. To save money, Fry said, he’s taking a less aggressive treatment route than his doctor recommended.

“There is no help for middle-class America,” he said.

More than 26 million Americans lacked health insurance in the first six months of 2024, according to the Centers for Disease Control and Prevention.

The uninsured are mostly low-income adults under age 65, and people of color, and most live in the South and West. The uninsured rate in the 10 states that, like Georgia, have not expanded Medicaid to nearly all low-income adults was 14.1% in 2023, compared with 7.6% in expansion states, according to KFF, a health information nonprofit that includes KFF Health News.

Health policy researchers expect the number of uninsured to swell as the second Trump administration and a GOP-controlled Congress try to enact policies that explicitly roll back health coverage for the first time since the advent of the modern U.S. health system in the early 20th century.

Under the “One Big Beautiful Bill Act” — budget legislation that would achieve some of President Donald Trump’s priorities, such as extending tax cuts mainly benefiting the wealthy — some 10.9 million Americans would lose health insurance by 2034, according to estimates by the nonpartisan Congressional Budget Office based on a House version of the budget bill.

A Senate version of the bill could result in more people losing Medicaid coverage with reductions in federal spending and rules that would make it harder for people to qualify. That bill suffered a major blow Thursday when the Senate parliamentarian, a nonpartisan official who enforces the chamber’s rules, rejected several health provisions — including the proposal to gradually reduce provider taxes, a mechanism that nearly every state uses to increase its federal Medicaid funding.

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The number who could lose insurance could rise to 16 million if proposed rule changes to the ACA take effect and tax credits that help people pay for ACA plans expire at the end of the year, according to the CBO. In KFF poll results released in June, nearly two-thirds of people surveyed viewed the bill unfavorably and more than half said they were worried federal funding cuts would hurt their family’s ability to obtain and afford health care.

Like Fry, more people would be forced to pay for health expenses out-of-pocket, leading to delays in care, lost access to needed doctors and medications, and poorer physical and financial health.

“The effects could be catastrophic,” said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured.

A patchwork system

The House-passed bill would represent the largest reduction in federal support for Medicaid and health coverage in history, Tolbert said. If the Senate approves it, it would be the first time Congress moved to eliminate coverage for millions of people.

“This would take us back,” she said.

The United States is the only wealthy country where a substantial number of citizens lack health insurance, due to nearly a century of pushback against universal coverage from doctors, insurance companies, and elected officials.

“The complexity is everywhere throughout the system,” said Sherry Glied, dean of New York University’s Wagner School of Public Service, who worked in the George H.W. Bush, Clinton, and Obama administrations. “The big bug is that people fall between the cracks.”

This year, KFF Health News is speaking to Americans about the challenges they face in finding health insurance and the effects on their ability to get care; to providers who serve the uninsured; and to policy experts about why, even when the nation hit its lowest recorded uninsured rate in 2023, nearly a tenth of the U.S. population still lacked health coverage.

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So far, the reporting has found that despite decades of policies designed to increase access to care, the very structure of the nation’s health insurance system creates the opposite effect.

Government-backed universal coverage has eluded U.S. policymakers for decades.

After lobbying from physician groups, President Franklin D. Roosevelt abandoned plans to include universal health coverage in the Social Security Act of 1935. Then, because of a wage and salary cap used to control inflation during World War II, more employers offered health insurance to lure workers. In 1954, health coverage was formally exempted from income tax requirements, which led more employers to offer the benefit as part of compensation packages.

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Insurance coverage offered by employers came to form the foundation of the U.S. health system. But eventually, problems with linking health insurance to employment emerged.

“We realized, well, wait, not everybody is working,” said Heidi Allen, an associate professor at the Columbia School of Social Work who studies the impact of social policies on access to care. “Children aren’t working. People who are elderly are not working. People with disabilities are not working.”

Yet subsequent efforts to expand coverage to all Americans were met with backlash from unions who wanted health insurance as a bargaining chip, providers who didn’t want government oversight, and those who had coverage through their employers.

That led policymakers to add programs piecemeal to make health insurance accessible to more Americans.

There’s Medicare for older adults and Medicaid for people with low incomes and disabilities, both created in 1965; the Children’s Health Insurance Program, created in 1997; the ACA’s exchange plans and Medicaid expansion for people who can’t access job-based coverage, created in 2010.

As a result, the U.S. has a patchwork of health insurance programs with numerous interest groups vying for dollars, rather than a cohesive system, health policy researchers say.

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Falling through the cracks

The lack of a cohesive system means even though Americans are eligible for health insurance, they struggle to access it, said Mark Shepard, an associate professor of public policy at the Harvard Kennedy School of Government. No central entity exists in the U.S. to ensure that all people have a plan, he said.

Over half of the uninsured might qualify for Medicaid or subsidies that can help cover the costs of an ACA plan, according to KFF. But many people aren’t aware of their options or can’t navigate overlapping programs — and even subsidized coverage can be unaffordable.

Those who have fallen through the cracks said it feels like the system has failed them.

Yorjeny Almonte of Allentown, Pennsylvania, earns about $2,600 a month as an inspector in a cabinet warehouse. When she started her job in December 2023, she didn’t want to spend nearly 10% of her income on health insurance.

But, last year, her uninsured mom chose to fly to the Dominican Republic to get care for a health concern. So Almonte, 23, who also needed to see a doctor, investigated her employer’s health offerings. By then she had missed the deadline to sign up.

“Now I have to wait another year,” she said.

In January, Camden, Alabama, resident Kiana George, who’s uninsured, landed in an intensive care unit months after she stopped seeing a nurse practitioner and taking blood pressure medications — an ordeal that saddled her with nearly $7,000 in medical bills.

George, 30, was kicked off Medicaid in 2023 after she got hired by an after-school program. It pays $800 a month, an income too high to qualify her for Medicaid in Alabama, which hasn’t expanded to cover most low-income adults. She also doesn’t make enough for a free or reduced-cost ACA plan.

George, who has a 9-year-old daughter, said she “has no idea” how she can repay the debt from the emergency room visit. And because she fears more bills, she has given up on treatment for ovarian cysts.

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“It hurts, but I’m just gonna take my chances,” she said.

Debating the high cost of care

Researchers have known for decades that a lack of insurance coverage leads to poor access to health care, said Tom Buchmueller, a health economist at the University of Michigan Ross School of Business.

“It’s only more recently we’ve had really good, strong evidence that shows that health insurance really does improve health outcomes,” Buchmueller said.

Research released this spring by the National Bureau of Economic Research found that expanding Medicaid reduced low-income adults’ chances of dying by 2.5%. In 2019, a separate study published by that nonpartisan think tank provided experimental evidence that health insurance coverage reduced mortality among middle-aged adults.

In late May, the House narrowly advanced the budget legislation that independent government analysts said would result in millions of Americans losing health insurance coverage and reduce federal spending on programs like Medicaid by billions of dollars.

A key provision would require some Medicaid enrollees to work, volunteer, or complete other qualifying activities for 80 hours a month, starting at the end of 2026. Most Medicaid enrollees already work or have some reason they can’t, such as a disability, according to KFF.

House Speaker Mike Johnson has defended the requirement as “moral.”

“If you are able to work and you refuse to do so, you are defrauding the system. You’re cheating the system,” he told CBS News in the wake of the bill’s passage.

A Senate version of the bill also includes work requirements and more frequent eligibility checks for Medicaid recipients.

Fiscal conservatives argue a solution is needed to curb health care’s rising costs.

The U.S. spends about twice as much per capita on health care than other wealthy nations, and that spending would grow under the GOP’s budget bill, said Michael Cannon, director of health policy studies at the Cato Institute, a think tank that supports less government spending on health care.

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But the bill doesn’t address the root causes of administrative complexity or unaffordable care, Cannon said. To do that would entail, for instance, doing away with the tax break for employer-sponsored care, which he said fuels excessive spending, high prices, and ties health insurance to employment. He said the bill should cut federal funding for Medicaid, not just limit its growth, to reduce excessive health care prices and spending.

The bill would throw more people into a high-cost health care landscape with little protection, said Aaron Carroll, president and CEO of AcademyHealth, a nonpartisan health policy research nonprofit.

“There’s a ton of evidence that shows that if you make people pay more for health care, they get less health care,” he said. “There’s lots of evidence that shows that disproportionately affects poor, sicker people.”

Labon McKenzie, 45, lives in Georgia, the only state that requires some Medicaid enrollees to work or complete other qualifying activities to obtain coverage.

He hasn’t been able to work since he broke multiple bones after he fell through a skylight while on the job three years ago. He got fired from a county road and bridge crew after the accident and hasn’t been approved for Social Security or disability benefits.

“I can’t stand up too long,” he said. “I can’t sit down too long.”

In February, McKenzie started seeing double, but canceled an appointment with an ophthalmologist because he couldn’t come up with the $300 the doctor wanted in advance. His cousin gave him an eye patch to tide him over, and, in desperation, he took expired eye drops his daughter gave him. “I had to try something,” he said.

McKenzie, who lives in rural Fort Gaines, wants to work again. But without benefits, he can’t get the care he needs to become well enough.

“I just want my body fixed,” he said.

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF.

Dramatic changes to the health care system, including Affordable Care Act (ACA) coverage, are on the horizon due to rule changes and the budget reconciliation bill from the Republican president and Congress. As a result, many Americans will see their premium costs skyrocket and many more could become disenrolled from their current plans.

Snapshot of Projected Increases for Vulnerable ACA Enrollees Under GOP Cuts

The average annual out-of-pocket premium increase will be 25 percent higher for rural enrollees than urban ones, with increases averaging $760 per year and climbing upwards of $3,000 or more in the nation’s hardest hit rural counties.

for than urban ones, with increases averaging and climbing upwards of in the nation’s hardest hit rural counties. The 12.8 million enrollees in HealthCare.gov plans who live in counties with high rates of diabetes would pay on average $559 more for coverage, and an estimated 2.8 million residents in those counties who previously were auto-reenrolled are at risk of losing coverage entirely —which could be life-threatening for people with diabetes.

in HealthCare.gov plans who would pay on average for coverage, and an estimated residents in those counties who previously were auto-reenrolled are —which could be life-threatening for people with diabetes. Around 8.9 million HealthCare.gov enrollees living in areas with lower than average access to primary care doctors—including 2.1 million older adults and 928,000 children—will pay an average of $619 more for their health plans, despite facing barriers to even accessing basic primary health care.

The ACA’s health insurance marketplaces offer people without access to Medicaid or affordable employer coverage quality, affordable private plans. The federal government provides premium tax credits to lower out-of-pocket premiums and runs these marketplaces in thirty-one states through HealthCare.gov. (State-based marketplaces operate in the remainder.)

Yet, after reaching record-high enrollment in January 2025, marketplace enrollment is projected to plunge in 2026 and thereafter due to higher out-of-pocket premiums and policies making it harder for people to get and stay covered. The nonpartisan Congressional Budget Office estimates that GOP plans for the marketplace would reduce federal funding by 40 percent and increase the number of uninsured Americans by over 8 million people in 2034—which doesn’t even count the additional millions of Americans who could face coverage loss due to proposed Medicaid changes.

Much of the forthcoming premium cost increases would result from sharp reductions in tax credits that Congress has yet proposed to extend that will raise out-of-pocket costs in January. Additionally, both a final rule from the Trump administration and proposals in the Republican Congress’s budget reconciliation bill would make it harder for people currently enrolled to stay covered. For example, the Trump rule ends the practice used in all other private insurance of re-enrolling people automatically if they like their plan and their circumstances haven’t changed. Enrollees will have to sign up and verify eligibility again to stay covered.

This is not inevitable: Congress could reject proposals that cause people to lose health insurance marketplace coverage and include the current level of premium tax credits among other tax changes extended in the budget reconciliation bill. It is a choice.

About the Project

This data dashboard shows how changes to the ACA marketplaces will affect Americans at the county and state levels in HealthCare.gov states. These states had 16.4 million of the 21 million marketplace enrollees nationwide in 2024. It focuses on counties facing extra challenges, including rural counties as well as those that have a higher than average percent of residents who have diabetes, are uninsured, and have less access to primary care. Information is available at the county and state level, with options to drill down to see the average annual out-of-pocket premium increase for health plans; the overall number of people, including older people and children, affected by the changes; the percent increase in enrollment between 2021 and 2024; and how many people were auto-reenrolled in 2024 who could be affected by Republican administrative and Congressional changes making it harder to keep coverage. Details are described in the methodology section.

Examples of state fact sheets can be found here: Alaska, Florida, Georgia, Louisiana, Nebraska, North Carolina, Ohio, Utah, West Virginia, and Wisconsin.

Key Findings

All HealthCare.gov states : In the thirty-one states that use the federally run HealthCare.gov, enrollment has nearly doubled since 2021 to 16.4 million people, including 3.7 million adults ages 55 to 64 and 1.7 million children. Enrollees receiving premium tax credits today would pay on average $624 more per year for the same coverage if Congress does not extend improvements to premium tax credits. Additionally, 3.6 million enrollees who were automatically re-enrolled in coverage would have to re-sign up under GOP proposals, causing some to lose coverage. States particularly hard hit by these plans include Alaska and Wyoming, whose average cost increases would exceed $1,800; Florida, which has the most enrollees (4.2 million); and West Virginia, which had the largest growth in enrollment (163 percent).

: In the thirty-one states that use the federally run HealthCare.gov, enrollment has nearly doubled since 2021 to 16.4 million people, including 3.7 million adults ages 55 to 64 and 1.7 million children. Enrollees receiving premium tax credits today would pay on average $624 more per year for the same coverage if Congress does not extend improvements to premium tax credits. Additionally, 3.6 million enrollees who were automatically re-enrolled in coverage would have to re-sign up under GOP proposals, causing some to lose coverage. States particularly hard hit by these plans include Alaska and Wyoming, whose average cost increases would exceed $1,800; Florida, which has the most enrollees (4.2 million); and West Virginia, which had the largest growth in enrollment (163 percent). Rural America: The average annual out-of-pocket premium for the 2.8 million residents of rural counties in HealthCare.gov states would increase by $760 without Congressional action, over 25 percent higher than the increase for urban residents. States with the largest average additional cost for health plans for rural enrollees include Wyoming ($1,943), Alaska ($1,835), and Illinois ($1,700). Texas, Georgia, and North Carolina have the highest number of rural HealthCare.gov enrollees who will face both higher prices and hurdles to remain covered. Rural enrollment growth since 2021 was highest in Georgia (222 percent), South Carolina (203 percent), Texas (190 percent), and Louisiana (173 percent).

The average annual out-of-pocket premium for the 2.8 million residents of rural counties in HealthCare.gov states would increase by $760 without Congressional action, over 25 percent higher than the increase for urban residents. States with the largest average additional cost for health plans for rural enrollees include Wyoming ($1,943), Alaska ($1,835), and Illinois ($1,700). Texas, Georgia, and North Carolina have the highest number of rural HealthCare.gov enrollees who will face both higher prices and hurdles to remain covered. Rural enrollment growth since 2021 was highest in Georgia (222 percent), South Carolina (203 percent), Texas (190 percent), and Louisiana (173 percent). Areas with high rates of diabetes: About 12.8 million enrollees in HealthCare.gov plans live in counties with high rates of diabetes, a pre-existing condition that requires lifelong medical care to manage. Currently enrolled people, including 2.8 million older adults, would pay on average $559 more for coverage because of Congress’s failure to extend premium tax credits. Additionally, an estimated 2.8 million residents in such counties who previously were auto-reenrolled are at risk of falling through the cracks and losing coverage, which could be life-threatening for a person with diabetes. The states that would experience the highest increase in annual premiums for their residents who live in counties with higher than average diabetes rates include Alaska ($2,136), Oregon ($1,413), West Virginia ($1,404), and South Dakota ($1,243). Texas has the largest number of enrollees (664,279) who would have to file new paperwork to stay covered.

About 12.8 million enrollees in HealthCare.gov plans live in counties with high rates of diabetes, a pre-existing condition that requires lifelong medical care to manage. Currently enrolled people, including 2.8 million older adults, would pay on average $559 more for coverage because of Congress’s failure to extend premium tax credits. Additionally, an estimated 2.8 million residents in such counties who previously were auto-reenrolled are at risk of falling through the cracks and losing coverage, which could be life-threatening for a person with diabetes. The states that would experience the highest increase in annual premiums for their residents who live in counties with higher than average diabetes rates include Alaska ($2,136), Oregon ($1,413), West Virginia ($1,404), and South Dakota ($1,243). Texas has the largest number of enrollees (664,279) who would have to file new paperwork to stay covered. Places where fewer people have health insurance: Health insurance marketplaces have provided affordable, quality health coverage in areas where employer and Medicaid coverage are limited. HealthCare.gov enrollment in counties with higher than average uninsured rates grew by 121 percent from 2021 to 2024, nearly twice the increase in counties with low uninsured rates (65 percent). Yet, in high uninsurance counties, 13.7 million HealthCare.gov enrollees, including families with 1.4 million children, would pay an average $564 more annually for their plans if Congress fails to extend enhanced premium tax credits. Nearly 3 million people would face challenges re-enrolling. The highest average increase in out-of-pocket costs for health plans for residents of high-uninsurance counties would be in Wyoming ($1,870) and Alaska ($1,840). In Florida, 455,078 children have coverage through HealthCare.gov in counties with high uninsured rates, putting them at risk of losing coverage.

Health insurance marketplaces have provided affordable, quality health coverage in areas where employer and Medicaid coverage are limited. HealthCare.gov enrollment in counties with higher than average uninsured rates grew by 121 percent from 2021 to 2024, nearly twice the increase in counties with low uninsured rates (65 percent). Yet, in high uninsurance counties, 13.7 million HealthCare.gov enrollees, including families with 1.4 million children, would pay an average $564 more annually for their plans if Congress fails to extend enhanced premium tax credits. Nearly 3 million people would face challenges re-enrolling. The highest average increase in out-of-pocket costs for health plans for residents of high-uninsurance counties would be in Wyoming ($1,870) and Alaska ($1,840). In Florida, 455,078 children have coverage through HealthCare.gov in counties with high uninsured rates, putting them at risk of losing coverage. Communities where accessing primary care is difficult: Around 8.9 million HealthCare.gov enrollees live in areas with high ratios of residents to primary care doctors. This means that the population need is greater than the supply so that such residents struggle to get basic care—and may struggle more depending on the outcome of the Congressional debate. Without action, HealthCare.gov enrollees with limited primary care access would pay $619 more on average for their health plans, including 2.1 million older adults and families with 928,000 children. The highest average increase in out-of-pocket costs for health plans for residents of counties with relatively few primary care providers would be in Alaska ($1,864) and Wyoming ($1,856). Louisiana and North Carolina have both a high number of counties with limited primary care access and large out-of-pocket cost increases unless Congress acts.

Methods: Data for this dashboard came from three sources: the U.S. Centers for Medicare and Medicaid Services (CMS); the U.S. Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy; and the University of Wisconsin Population Health Institute, County Health Rankings & Roadmaps 2025.

CMS was the source for all health insurance marketplace data. The increase in out-of-pocket premiums when the enhanced tax credits expire was based on data from Other Resources in a file called “ARP/IRA Savings for HC.gov OE 2024 Plan Selections made by Consumers who Elected to Receive APTC by county (XLSX).” The difference between the Advanced Premium Tax Credit (APTC) with and without the ARP/IRA changes was calculated through subtraction and multiplied by twelve to annualize. State and HealthCare.gov averages were calculated by weighting the county averages by county enrollees who received APTC. Data on overall marketplace enrollment, enrollment by age, and the number of enrollees who were auto-reenrolled were from 2024 Marketplace Open Enrollment Period Public Use Files in the file called “2024 OEP County-Level Public Use File (ZIP).” The 2024 overall enrollment data were compared to 2021 overall marketplace enrollment to calculate the percent change in enrollment; the 2021 overall enrollment was from 2021 Marketplace Open Enrollment Period Public Use Files in a file called “2021 OEP County-Level Public Use File (ZIP).” State and HealthCare.gov enrollment counts were cumulated from the county data.

The analysis categorized a county as “rural” when the HRSA data labeled it “Fully FORHP Rural Counties.” The County Health Rankings for 2025 were used for the dichotomous categorization of counties as high or low diabetes, high or low uninsured, and high or low primary care ratio. The years, definitions, and sources of these variables can be found here. This analysis’s categorization of counties was done by calculating a national average from the county data for each of these variables and categorizing the county as “high” or “low” by comparing it to the variable’s national average. State and HealthCare.gov average annual out-of-pocket premium increases were calculated as weighted averages of the county enrollment in the categorization (see above). Enrollment counts at the state and HealthCare.gov levels were cumulated. Additional information is available upon request.

Acknowledgements: The authors would like to thank the Harvard University students in the Charles River Economics Lab, Stephanie Chen, Sophia Lichterfeld, Tinaye Ngorima, Chloe Sow, Michael Wang, and Iris Xue, who assisted with data analysis. The authors would especially like to thank Stephanie Chen, who acted as a project coordinator and assisted with data visualization as well.

Note: KFF’s analysis was updated on June 6 to reflect new estimates from the Congressional Budget Office (CBO) on the increase in the number of people who would be without health insurance because of changes to Medicaid and the ACA in the House’s version of the One Big Beautiful Bill Act.

House Republicans have passed a reconciliation package (the “One Big Beautiful Bill Act”) that would make significant changes to Medicaid and the Affordable Care Act (ACA) Marketplaces. The Congressional Budget Office (CBO) estimates that the bill would increase the number of people without health insurance by 10.9 million, because of changes to Medicaid and the ACA. Additionally, these legislative changes come at a time when enhanced premium tax credits for ACA Marketplace enrollees are set to expire later this year. When combining the reconciliation bill’s effects with that of the expected expiration of the ACA’s enhanced premium tax credits, CBO expects 16.0 million more people will be uninsured in 2034 than would otherwise be the case.

This analysis apportions the increase in the number of uninsured across the 50 states and the District of Columbia and shows that number as a percentage of each state’s population. The number of newly uninsured as a percent of the population is equivalent to the percentage point increase in the 2034 uninsured rate. Nationally, CBO projected an uninsured rate of under 10% in 2034 under current law, which assumed the enhanced ACA premium tax credits would expire. The analysis here includes two maps: one showing the effects of the House reconciliation package, and another showing those effects combined with expiration of the ACA enhanced premium tax credits and full impact of the program integrity rule.

Anticipating how states will respond to changes in Medicaid policy is a major source of uncertainty in CBO’s cost estimates. Instead of making state-by-state predictions about policy responses, CBO estimates the percentage of the affected population that lives in states with different types of policy responses. For example, in the reconciliation bill, Medicaid work requirements account for nearly half of the federal savings on Medicaid, suggesting they may contribute to the largest loss of insurance coverage in CBO’s estimates. However, different states might choose to implement a work requirement with reporting requirements that are easier or harder for enrollees to comply with. Reflecting the uncertainty, this analysis illustrates the potential variation by showing a range of enrollment effects in each state, varying by plus or minus 25% from a midpoint estimate.

The interactive table at the end is sortable by state and size of coverage loss.

The One Big Beautiful Bill Act would result in increases in the uninsured rates of 3 percentage points or more in 16 states (Washington, Oregon, Louisiana, New York, Kentucky, Florida, California, Illinois, New Mexico, Rhode Island, Connecticut, Arizona, New Jersey, West Virginia, Arkansas and Alaska) and District of Columbia. These increases are attributable to the One Big Beautiful Bill Act alone and do not include the effect of the expiration of the enhanced premium tax credits nor the full impact of the proposed Marketplace integrity rule.

In terms of increases in the number of uninsured people, California and Florida are the top two states (1.7M and 990k, respectively). New York, Texas, and Illinois would follow at 920K, 770k, and 500k, respectively.

The combined effects of the House reconciliation package with the expiration of the ACA enhanced tax credits, compared to a scenario where the enhanced subsidies are in place and the proposed integrity rule was not in effect, results in the greatest uninsured increases in Florida, Georgia, Louisiana, Texas, Mississippi, Washington, and the District of Columbia, where the uninsured rate is expected to increase by at least 5 percentage points. Thirty-five states and the District of Columbia may see an increase in their uninsured rates of 3 percentage points or more.

About half (48%) of the 16 million more people who would be uninsured in this scenario live in Florida (2.3M), Texas (1.9M), California (1.8M), New York (920k), and Georgia (750k). The largest growth in ACA Marketplace enrollment since 2020, the year before the enhanced premium tax credits became available, occurred in Texas (2.8M), Florida (2.8M), and Georgia (1.0M).