Washington, D.C. — As 2026 Affordable Care Act (ACA) marketplace open enrollment begins November 1, a new analysis from the Center for American Progress finds that 92 percent of low-income Americans enrolled in marketplace coverage live in states that voted for President Donald Trump in 2024.
Enrollees with family incomes from 100 percent to 150 percent of the federal poverty level are guaranteed a $0 premium silver-plan option under the enhanced premium tax credits, but that would no longer be the case if the enhanced financial help expires at the end of the year. Unless Congress acts, they are among those most at risk of losing coverage.
The analysis warns that the expiration of the enhanced premium tax credits and the Trump administration’s new “marketplace integrity and affordability” rule are on track to drive up premiums and restrict enrollment options for millions of low-income families, young adults, and self-employed workers nationwide.
“Millions of Americans will see their $0 premiums disappear overnight if Congress fails to act,” said Natasha Murphy, director of Health Policy at CAP and author of the analysis. “Nine out of 10 low-income marketplace enrollees live in states that voted for Trump, and they’re about to be hit hardest by his administration’s decisions.”
The analysis examines how these two major policy shifts would combine to make 2026 open enrollment one of the most consequential years since the ACA’s passage:
- 92 percent of low-income enrollees live in Trump-voting states. CAP’s new estimate finds that 9 in 10 marketplace enrollees with family incomes from 100 percent and 150 percent of the federal poverty level live in states that Trump won in 2024, many of which never expanded Medicaid.
- $0 premiums vanish. For this group, the enhanced premium tax credits reduced monthly costs to $0 for benchmark silver plans. Their premiums are set to rise by hundreds or even thousands of dollars per year if Congress does not extend the credits.
- Enrollment barriers increase. The Trump administration’s new rule eliminated the special enrollment period for low-income people, locking out those who miss open enrollment or lose coverage midyear.
- Premiums surge for young adults. A 27-year-old in Miami earning $25,000 could see annual premium costs rise from $156 to $5,052 without enhanced credits—more than a 3,000-percent increase.
- Small-business owners squeezed. Nearly half of all adult marketplace enrollees are self-employed or work for small businesses. Higher premiums will make it harder to maintain coverage or keep employees insured.
CAP’s analysis underscores the urgency of congressional action to extend and make permanent the enhanced premium tax credits. Without it, millions of Americans could lose access to comprehensive, affordable coverage as early as January 2026.
Read the full analysis: “Open Enrollment, Closed Doors“ by Natasha Murphy
For more information or to speak with an expert, contact Christian Unkenholz at [email protected].