In 2024, 18.9 million people ages 18–64 enrolled in health insurance plans through federal and state-based marketplaces, of which 4.9 million were between the ages of 50 and 64. The vast majority (17.3 million of those ages 18–64, including 4.5 million adults ages 50–64) received enhanced premium tax credits to help cover their health insurance premiums. By 2026, the number of individuals estimated to receive enhanced premium tax credits is forecast to grow to more than 18 million, of which 4.8 million are expected to be ages 50–64. The enhanced premium tax credits, however, are set to expire at the end of 2025 if Congress does not extend them. Without an extension of the enhancements, these 18 million Americans who are expected to benefit from the enhancements will be left with fewer and potentially no tax credits to purchase private health insurance on the marketplaces.

Background

The Affordable Care Act (ACA) authorized premium tax credits (PTCs) to qualified individuals with incomes 100–400% of the Federal Poverty Level (FPL) who buy private plans on the individual health marketplaces. Plans in the marketplace fall within four categories of increasing coverage: Bronze, Silver, Gold, and Platinum. PTCs are benchmarked to the cost of the second lowest-cost Silver plan in a market and then vary based on individuals’ household incomes. The American Rescue Plan Act (ARPA) of 2021 enhanced the PTCs to fully subsidize Silver-plan premiums for individuals with incomes up to 150% FPL, provide larger tax credits for people with incomes up to 400% FPL, and allow people earning over 400% FPL to qualify for PTCs when marketplace coverage exceeds 8.5% of their income. ARPA initially established the enhancements through 2022; the 2022 Inflation Reduction Act extended the enhancements through 2025.

Between 2020 and 2024, marketplace enrollment increased to record highs, in part due to the PTC enhancements and new enrollments resulting from Medicaid redeterminations, which followed the end of the maintenance of effort requirement associated with the COVID-19 public health emergency. Avalere Health research shows that between April 2023 and September 2024, over 29 million individuals were disenrolled from Medicaid across 50 states and the District of Columbia, of which nearly 4 million were between the ages of 50 and 64. Approximately 10 million of the individuals who were disenrolled from Medicaid (of which 1.3 million were ages 50–64) may be eligible for enhanced tax credits to purchase private insurance through the marketplaces.

Enhancements to the PTCs, which made premium tax credits more generous and available to more people, are currently authorized through December 31, 2025. As that expiration approaches, health plans will need to develop and submit premium rates for regulatory review by mid-year for the 2026 plan year. Given the uncertainty, Congressional inaction in early 2025 may lead plans to develop higher bids and premiums for the 2026 plan year, raising consumer costs and introducing instability in the ACA Marketplaces.

Ultimately, if the enhancements are not extended beyond 2025, individuals who have received enhanced PTCs will likely face higher premium costs to maintain current coverage and could look to lower-cost metal tiers or forgo enrolling in a marketplace plan. These decisions could affect access to medical care and treatment on an individual level and contribute to rising marketplace premiums more broadly if the risk pool were adversely impacted.

Analysis

AARP commissioned Avalere Health to quantify the number of marketplace enrollees who could benefit from enhanced PTCs in 2026 if the enhancements are extended or made permanent, with a focus on adults ages 50–64. In other words, these estimates are the number of enrollees who would be impacted if the enhancements were to expire at the end of 2025. The analysis was conducted at the national, state, and county levels for all 50 states and the District of Columbia.

Key Findings

Avalere Health estimated that nearly 20 million Americans between the ages of 18 and 64, of which 5.2 million are ages 50–64, will purchase private insurance coverage through state and federally facilitated marketplaces during the 2026 Open Enrollment Period (OEP) if the enhanced PTCs are extended. The vast majority of these consumers (91%, or 18 million) may be eligible to receive enhanced PTCs to purchase coverage if the enhancements are extended. Among eligible individuals ages 18–64, approximately 25% are Hispanic, 12% are Black, and 8% are Asian. For both age categories—50–64 and the entire 18–64 population— about half of those eligible to receive enhanced PTCs are women (51%) and almost half (49%) are White. Of the more than 18 million Americans eligible for enhanced PTCs, close to 4.8 million (26%) are between the ages of 50 and 64 (Figure 1). For those individuals who live in rural areas and are expected to enroll in marketplace coverage in 2026, 91% are estimated to be eligible to receive the enhanced PTCs, if re-authorized.

Figure 1. Estimated Number of Marketplace Consumers by Eligibility for Enhanced Tax Credits, 2026

Avalere Health estimated average marketplace premiums with and without the enhanced tax credits to demonstrate the impact of the enhanced PTCs for marketplace enrollees ages 50–64. Depending on individual income level, enhanced PTCs are estimated to save marketplace enrollees ages 50–64 between $599 and $4,574 per year (Table 1). If the enhancements expire, marketplace enrollees would face substantially higher premium costs, which could make it impractical for many to maintain their coverage. This change is particularly large among enrollees in the 400% to 500% FPL group, who are currently saving an estimated $4,574 in annual premiums.

Table 1: Estimated Annual Premiums Savings and Enrollment, Ages 50–64 by Income Level, 2026

Source: Avalere Health analysis of 2024 OEP Public Use Enrollment (PUF) and American Community Survey 2023 1-Year Sample.

*AK and HI premiums are excluded due to data limitations.
** Avalere Health estimates that there are 2.3 million marketplace enrollees age 50–64 with incomes not elsewhere specified are omitted.

Avalere Health also analyzed state- and county-level enrollment, premium, and demographic data to demonstrate the local impact of extending the enhanced PTCs or making them permanent. By analyzing county-level data, Avalere Health estimates that 680,000 people ages 50–64 will enroll in the marketplace during the 2026 OEP reside in rural counties. Of those individuals who reside in rural counties and purchase private coverage through the marketplaces, 91% may be eligible to receive enhanced tax credits. The map below provides state and county level enrollment and premium information, with a focus on the 50–64 population.

Hover over or click on each state or county to see additional information.

Methodology

Avalere Health projected 2026 enrollment in private plans purchased through health marketplaces utilizing 2022–2024 enrollment numbers from the Center for Medicare and Medicaid Services (CMS) and enrollment growth projections from the Congressional Budget Office. The Public Use Files (PUFs) provided by CMS include enrollment numbers for each state by age, gender, race/ethnicity, and FPL. The PUFs also include premium and tax credit information. For county-level information, Avalere Health utilized the PUFs to determine enrollment and premium information by demographic factor for counties within states that use the federal marketplace. PUFs do not include county-level information for counties within states that utilize a state-based marketplace (SBM). To project enrollment by demographic factor for counties within states that utilize an SBM, Avalere Health utilized the Census Bureau’s American Community Survey 5-Year Estimates to estimate figures proportionally based on population size of each county in comparison to the respective state’s total population. For premium and tax credit information for these counties, Avalere Health assigned the respective state average amount for all counties within the state.

Funding for this research was provided by the AARP Public Policy Institute. Avalere Health retained full editorial control.