The ACA provides low- and middle-income individuals with premium tax credits to purchase health coverage on the exchange. Originally authorized by the American Rescue Plan Act in 2021, enhanced PTCs were later extended by the Inflation Reduction Act. Without another congressional extension, the PTCs will expire at the end of 2025.
As of January 2025, 24 million people are enrolled in an exchange plan. Without a PTC extension, an estimated 4 million people will become uninsured, creating a ripple effect across the healthcare industry and wider economy.
Without an extension, total state GDPs would fall by $34.1 billion and total economic output would decrease by $57 billion. The list below ranks states by the estimated change in total economic activity if an extension does not occur. The list also includes the estimated change in federal funding due to the elimination of enhanced PTCs.
“It should be noted that our estimates are conservative,” Commonwealth Fund researchers wrote. “They do not account for the potential loss of productivity likely to result when people who lose access to affordable insurance, and thus affordable medical care, are unable to work because of a decline in their health status.”
States ranked by the change in economic output in 2026 if premium tax credits expire:
- Texas
Economic output change: −$14.1 billion
Federal funding loss: −$6.3 billion - Florida
Economic output change: −$9.5 billion
Federal funding loss: −$4.2 billion - Georgia
Economic output change: −$5.5 billion
Federal funding loss: −$2.5 billion - Tennessee
Economic output change: −$2.8 billion
Federal funding loss: −$1.3 billion - Louisiana
Economic output change: −$2.1 billion
Federal funding loss: −$968.6 million - South Carolina
Economic output change: −$2.1 billion
Federal funding loss: −$996 million - Alabama
Economic output change: −$1.9 billion
Federal funding loss: −$923 million - Mississippi
Economic output change: −$1.56 billion
Federal funding loss: −$728 million - Ohio
Economic output change: −$1.55 billion
Federal funding loss: −$708 million - California
Economic output change: −$1.5 billion
Federal funding loss: −$716 million - Arizona
Economic output change: −$1.1 billion
Federal funding loss: −$487 million - North Carolina
Economic output change: −$1 billion
Federal funding loss: −$479 million - New York
Economic output change: −$990 million
Federal funding loss: −$479 million - Indiana
Economic output change: −$937 million
Federal funding loss: −$447 million - New Jersey
Economic output change: −$879 million
Federal funding loss: −$428 million - Kentucky
Economic output change: −$840 million
Federal funding loss: −$391 million - Missouri
Economic output change: −$736 million
Federal funding loss: −$344 million - Oklahoma
Economic output change: −$722 million
Federal funding loss: −$340 million - Kansas
Economic output change: −$721 million
Federal funding loss: −$344 million - Arkansas
Economic output change: −$626 million
Federal funding loss: −$295 million - Utah
Economic output change: −$572 million
Federal funding loss: −$258 million - Colorado
Economic output change: −$522 million
Federal funding loss: −$243 million - West Virginia
Economic output change: −$497 million
Federal funding loss: −$240 million - Idaho
Economic output change: −$481 million
Federal funding loss: −$227 million - Pennsylvania
Economic output change: −$448 million
Federal funding loss: −$208 million - Oregon
Economic output change: −$418 million
Federal funding loss: −$200 million - Virginia
Economic output change: −$413 million
Federal funding loss: −$202 million - Illinois
Economic output change: −$388 million
Federal funding loss: −$181 million - Minnesota
Economic output change: −$370 million
Federal funding loss: −$172 million - Maryland
Economic output change: −$263 million
Federal funding loss: −$128 million - Wyoming
Economic output change: −$208 million
Federal funding loss: −$105 million - Washington
Economic output change: −$196 million
Federal funding loss: −$97 million - Michigan
Economic output change: −$193 million
Federal funding loss: −$88 million - Delaware
Economic output change: −$153 million
Federal funding loss: −$75 million - Alaska
Economic output change: −$152 million
Federal funding loss: −$76 million - Nevada
Economic output change: −$135 million
Federal funding loss: −$65 million - South Dakota
Economic output change: −$133 million
Federal funding loss: −$65 million - Nebraska
Economic output change: −$127 million
Federal funding loss: −$62 million - Connecticut
Economic output change: −$129 million
Federal funding loss: −$64 million - Iowa
Economic output change: −$99 million
Federal funding loss: −$49 million - New Hampshire
Economic output change: −$88million
Federal funding loss: −$42 million - Vermont
Economic output change: −$73 million
Federal funding loss: −$35 million - Maine
Economic output change: −$56 million
Federal funding loss: −$26 million - Wisconsin
Economic output change: −$27 million
Federal funding loss: −$15 million - Montana
Economic output change: −$30 million
Federal funding loss: −$15 million - Hawaii
Economic output change: −$30 million
Federal funding loss: −$15 million - District of Columbia
Economic output change: −$12 million
Federal funding loss: −$6 million - North Dakota
Economic output change: +$15 million
Federal funding loss: +$6 million - Rhode Island
Economic output change: +$34 million
Federal funding loss: +$16 million - New Mexico
Economic output change: +$103 million
Federal funding loss: +$50 million - Massachusetts
Economic output change: +$348 million
Federal funding loss: +$166 million