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The numbers are staggering. The Urban Institute projects 4.8 million Americans will become uninsured in 2026 following the expiration of enhanced ACA premium tax credits, representing a 21 percent increase in the nation’s uninsured population.

Behind every statistic is a real person making impossible choices. In Thompson’s Station, Tennessee, Robert Sory had been paying $0 monthly for his marketplace plan. When he checked 2026 rates, even a bare-bones bronze plan would cost at least $70 per month. He dropped coverage entirely.

“When you don’t have any income coming in, it doesn’t matter how cheap it is,” Sory told reporters in a recent KFF Health News investigation on Americans losing ACA coverage. “It’s not affordable.”

His wife Emily, who lost her job and insurance simultaneously in November, now pays $184 out-of-pocket for three monthly prescriptions. As Robert noted, that amount equals 350 pounds of food for the animals at their nonprofit sanctuary.

Geographic Concentration of Coverage Loss

The damage falls unevenly across America. Eight states will see their subsidized marketplace enrollment drop by more than half: Georgia, Louisiana, Mississippi, Oregon, South Carolina, Tennessee, Texas, and West Virginia.

Mississippi faces the most severe impact. The state’s uninsured rate is projected to jump 65 percent, the highest increase nationwide. South Carolina follows at 50 percent. Understanding how premium increases affect real families requires examining the broader context of ACA Subsidy Crisis: What the Expiration Means for 22 Million Americans.

Ten states still have not expanded Medicaid, creating a coverage gap that hits low-income workers hardest. Adults in these states who earn too much for traditional Medicaid but too little to afford marketplace plans have nowhere to turn. Tennessee, Texas, Georgia, and Mississippi all fall into this category.

Mississippi’s rural hospitals will lose approximately $200 million in 2026 without the enhanced subsidies, according to Commonwealth Fund projections. More than half of Mississippi’s rural hospitals are already at risk of closing.

Demographic Disparities

The coverage losses hit certain communities disproportionately hard. Black Americans face a projected 22 percent increase in uninsurance. Young adults between 19 and 34 will see a 25 percent increase, notably higher than increases for older adults.

The Urban Institute found that Black Americans will experience the largest raw numbers, with 925,000 more Black people becoming uninsured in 2026. The Economic Policy Institute estimates this will result in more than 200 preventable deaths annually in major metropolitan areas alone.

Hispanic Americans face a 15 percent increase in uninsurance, though new immigration eligibility restrictions that took effect January 1 compound the challenge. Several categories of lawfully present immigrants, including refugees, asylees, and trafficking survivors, lost eligibility for premium subsidies entirely.

Economic Ripple Effects

Healthcare providers face a financial reckoning. The Urban Institute projects $32.1 billion in lost provider revenue for 2026, with a $7.7 billion increase in uncompensated care demand. Hospitals, particularly in rural areas, will absorb much of this burden.

The broader economy takes a hit as well. A recent Becker’s Payer Issues analysis of states facing the steepest coverage losses found total state GDPs will fall by $34.1 billion and overall economic output will decrease by $57 billion nationwide. Healthcare employment alone will decline by 130,000 positions, with Texas losing 30,800 healthcare jobs and Florida losing 22,100.

For families just above 400 percent of the federal poverty level, the return of the subsidy cliff creates particular hardship. Annual premiums for this group would jump from approximately $4,400 to $8,500. About 725,000 people fall in the narrow band between 400 and 500 percent of poverty, earning too much for any assistance but far too little to absorb a doubling of costs.

The Path Forward Remains Uncertain

The House passed legislation extending the expired subsidies on January 8, but the bill faces an uncertain future in the Senate. Political dynamics examined in 17 Republicans Defy Leadership: House Passes ACA Extension in Rare Revolt show both the challenges and possibilities for legislative action.

Hospitals and clinics are bracing for the influx of newly uninsured patients. Federally qualified health centers, which offer sliding-scale fees based on ability to pay, expect surging demand. Nonprofit organizations like Dispensary of Hope, which distributes donated medications through 277 sites in 38 states, are asking pharmaceutical companies to increase donations.

For the Sory family in Tennessee and millions like them, the math remains brutal. Emily Sory already carries substantial medical debt from necessary care. Her plan if Congress fails to act? Drop her own coverage and keep insurance only for her 4-year-old daughter.

“I understand the system,” she said. “And I get it’s people like me that don’t pay their bill are why it suffers. And I feel bad. But at the same time, I don’t have the money to pay it.”

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About the Author

Jim Toppe is the founder of Toppe Consulting, a digital marketing agency specializing in law firms. He holds a Master of Science in Management from Clemson University and teaches Business Law and Marketing at Greenville Technical College. Jim also serves as publisher and editor for South Carolina Manufacturing, a digital magazine. His unique background combines legal knowledge with digital marketing expertise to help attorneys grow their practices through compliant, results-driven strategies.

Works Cited

Farmer, Blake. “Millions of Americans Are Expected To Drop Their Affordable Care Act Plans. They’re Looking for a Plan B.” KFF Health News, 12 Jan. 2026, https://kffhealthnews.org/news/article/aca-enhanced-subsidies-obamacare-uninsured-drop-coverage-medicaid-gap/.

Emerson, Jakob. “States facing steepest coverage losses after ACA subsidies expire.” Becker’s Payer Issues, 2 Jan. 2026, https://www.beckerspayer.com/payer/aca/states-facing-steepest-coverage-losses-as-aca-subsidies-expire/.

Related Articles

• ACA Subsidy Crisis: What the Expiration Means for 22 Million Americans
• 17 Republicans Defy Leadership: House Passes ACA Extension in Rare Revolt

Disclaimer

This article is for informational purposes only and does not constitute legal or healthcare advice. Individuals should consult qualified professionals for guidance on their specific situations.