For four years, people who buy their own health insurance got enhanced tax credits that held their premiums down. Those credits expired at the end of 2025. Congress could have extended them. It didn't.

We now know exactly what that cost.

Nationally, the number of people actually enrolled and paying for ACA coverage fell from 21,776,626 to 19,169,147 — a loss of 2,607,479 people, or 12%, in a single year. That's after seven straight years of growth, and it's KFF's own July 28 analysis of federal data, not a projection.

Premiums rose an average of 58% without the credits. Enrollment fell in 49 of 50 states. The only exception was New Mexico, which spent state money to fill the gap.

Here is where the damage was worst:

State	Lost coverage	Drop
Ohio	161,385	−32%
Oklahoma	85,557	−32%
Arizona	107,183	−30%
South Carolina	159,190	−29%
Indiana	78,096	−28%
Michigan	130,789	−27%
Mississippi	68,658	−26%
Missouri	86,425	−25%
Alabama	94,311	−23%
North Carolina	164,682	−21%
Florida	442,785	−10%
Texas	146,345	−4%

Two votes decided this. On December 11, 2025, Senate Republicans blocked S. 3385, which would have extended the credits — the motion to even begin debate got 51 of the 60 votes it needed. Six days later, on December 17, the House passed H.R. 6703, 216–211, a bill titled the "Lower Health Care Premiums for All Americans Act" that contains no extension of the credits at all.

These are the members whose own states got hit hardest — and who voted for it anyway.

Jim Jordan — Ohio, −32%

No state lost a larger share of its coverage than Ohio, which tied Oklahoma at the top: 161,385 Ohioans, nearly a third of the state's marketplace, gone in a single year. Only Florida and North Carolina lost more people outright, and both are far bigger states.

Jim Jordan voted yes on the House bill.

Ohio's own numbers were not a surprise to anyone in its delegation. An estimated 356,000 Ohio residents are projected to lose health coverage under the Trump spending law — and that projection was published in March 2026 with the note that it came on top of the 113,000 Ohioans who had already lost coverage when the tax credits were allowed to expire. The state also stands to lose an estimated $33 billion in federal Medicaid funds over the next decade.

Jordan is not a backbencher who got rolled by leadership. He is chairman of the House Judiciary Committee, a founder of the Freedom Caucus, and one of the handful of members who can genuinely move House Republicans when he wants to. When Jordan decides something matters, the conference hears about it.

He has been in Congress since 2007 — nineteen years — and in that time has never sponsored a single bill that became law. Not one.

That is the record he brings to the worst-hit state in the country: maximum leverage, and nothing built with it.

Stephanie Bice — Oklahoma, −32%

Stephanie Bice voted yes on the House bill. Oklahoma lost 85,557 people, tied for the steepest percentage drop in the country.

Bice went to Congress saying she would fight for affordable health care. She then voted against capping insulin at $35 a month and against letting Medicare negotiate lower drug prices — in a state where 13.2% of adults have been told they have diabetes.

But the number that captures this best is a single Oklahoma household. With the enhanced subsidies gone, a 60-year-old Oklahoma couple earning $85,000 saw annual premiums go from $7,225 to $30,784.

That is not a rate increase. That is a family being removed from the insurance market. And $85,000 for a couple is precisely the income the enhanced credits were designed to reach — people who earn too much for the old subsidy cliff and nowhere near enough to absorb a $30,000 premium.

Oklahoma hospital leaders also warn that the budget bill Bice voted for will cut reimbursements to Oklahoma hospitals by $8.7 billion over the next decade and eliminate nearly 15,000 jobs. Ten Oklahoma hospitals have already closed.

Juan Ciscomani — Arizona, −30%

Juan Ciscomani voted yes. Arizona lost 107,183 people, a 30% collapse.

Ciscomani represents a swing district and has spent two years insisting he's a moderate on health care. The arithmetic doesn't care about positioning. Arizona's marketplace shed nearly a third of its enrollment in twelve months — 107,183 people who were paying for coverage in 2025 and are not in 2026.

That is the part that gets missed about the subsidy expiration. When 107,000 people lose insurance, they don't stop getting sick. They show up at an emergency room uninsured, and the hospital absorbs the bill. In rural Arizona there isn't much hospital left to absorb it.

It also fits his pattern. Six weeks after 700 people in Casa Grande lost their jobs, Ciscomani brought the Speaker of the House there to celebrate. The announcement and the aftermath keep pointing in opposite directions.

Sheri Biggs — South Carolina, −29%

Sheri Biggs voted yes. South Carolina lost 159,190 people — the fourth-largest raw loss in the country, from a state of five million.

Biggs is a nurse practitioner. She has spent a career in exam rooms with patients who couldn't afford care.

In her own district, an estimated 27,623 people in SC-03 are projected to lose health coverage — 24,900 of them losing ACA marketplace coverage, 2,723 losing Medicaid, according to the Joint Economic Committee.

She, more than almost anyone who cast this vote, knows exactly what happens to a person who stops being able to afford their medication. She voted for it anyway.

Victoria Spartz — Indiana, −28%

Indiana lost 78,096 people, more than a quarter of its marketplace. Victoria Spartz voted yes.

On top of that, an estimated 650,000 Hoosiers on Medicaid expansion are at risk of losing coverage under the budget bill — a number that would devastate hospitals and rural communities across the state.

What separates Spartz from most of this list is that she actually showed up to hear about it.

In late March 2025, after Speaker Mike Johnson encouraged Republicans to skip town halls, Spartz became the first House Republican in Indiana to hold one anyway — two events on back-to-back days, in Westfield and Muncie. Credit where it's due; most of her colleagues hid.

Then she stood there while her constituents chanted "Do your job!" and protested outside.

Showing up is the first step. It isn't the whole job. Spartz heard directly from Hoosiers about what these cuts would do, in a room, to her face — and eight months later voted for the bill that let their premiums jump anyway.

Lisa McClain — Michigan, −27%

Michigan lost 130,789 people. Lisa McClain voted yes.

McClain is not a rank-and-file member. She serves as House Republican Conference Chair — the fourth-highest position in House Republican leadership. She is in the room where the conference decides what it will and won't bring to the floor.

Michigan was already exposed. An estimated 200,000 Michiganders are projected to lose Medicaid coverage under the budget bill, which could also blow a $2 billion hole in the state budget — because 70% of Michigan's Medicaid spending comes from federal dollars.

Stack that on 130,789 people already out of the marketplace, and Michigan is absorbing losses from two directions at once. The member of its delegation with the most influence over what House Republicans do next is the one who helped set the agenda that produced it.

Michael Guest — Mississippi, −26%

Michael Guest voted yes. Mississippi lost 68,658 people — in the state that can least afford it.

Mississippi already runs on Medicaid: 714,600 people, or 24.3% of the entire state population, were covered by it in 2024. It is also one of the ten states that never expanded Medicaid, so working-age adults who lose marketplace coverage there usually have nowhere else to go.

Guest has form on this. He spent his August recess promoting $206 million for Mississippi's rural hospitals — after voting for the law that took billions away from them. The pattern repeats: vote for the cut, announce the crumb.

Jason Smith — Missouri, −25%

Missouri lost 86,425 people. Jason Smith voted yes — and he is the single member on this list with the clearest jurisdiction over the thing that expired.

Smith chairs the House Ways and Means Committee, the most powerful tax committee in Congress. He writes the nation's tax laws.

The enhanced ACA premium tax credits are, literally, a tax credit. They live in the tax code. Extending them is a Ways and Means matter. When people ask which committee could have moved an extension through the House, the answer is his — and he has held the gavel since 2023.

Missouri's own reporting matches the federal numbers almost exactly: more than 86,000 Missourians dropped ACA marketplace coverage between February 2025 and February 2026 — a nearly 25% decline, among the steepest in the country — explicitly attributed to the expiration of the enhanced credits. Two independent sources, the same answer.

And the forecast was published before the vote. An estimated 160,000 more Missourians are projected to be uninsured by 2034 under the budget bill — rising to 230,000 if the enhanced ACA premium tax credits were also allowed to expire.

They were allowed to expire. The chairman of the committee that writes tax law voted for the bill that didn't extend them.

Virginia Foxx — North Carolina, −21%

North Carolina lost 164,682 people — the largest raw loss of any state in this group, and second nationally only to Florida.

Virginia Foxx voted yes. And of everyone on this list, she is the one who most directly controlled whether the House got to vote on anything else.

Foxx chairs the House Rules Committee. That is the panel that decides what reaches the floor and which amendments may even be offered — Speaker Johnson appointed her to it. Nothing gets a vote in the House of Representatives without going through her committee first.

So consider what the House actually voted on in December. Not an extension of the expiring credits. A substitute bill that doesn't extend them, brought to the floor under a rule.

Foxx has been in Congress since 2005 — twenty-one years — and is the former chair of the Education and the Workforce Committee, which writes the rules for employer health plans. She is not a member who lacks the standing or the procedural knowledge to force a health care vote. She is the member who decides which ones happen.

Meanwhile North Carolina stands to lose an estimated $49.9 billion in federal Medicaid funds over the next decade, with another 195,000 residents projected to lose coverage on top of the 164,682 already gone.

Roger Marshall — Kansas, −20%

Roger Marshall is the one who said the quiet part out loud, and he's a doctor.

Marshall is an OB-GYN who sits on the Senate's health committee. He voted to block the extension. Kansas lost 36,040 people, a 20% drop.

Asked about the expiring subsidies in December 2025, he shrugged: some people's premiums, he said, "are going to go up some."

They went up 58%. In Oklahoma next door, one couple's went up 326%.

This is the same senator who once explained the uninsured this way: "There is a group of people that just don't want health care."

A physician is allowed to hold conservative views about how health care should be financed. What's harder to defend is a physician who describes a 58% premium spike as going up "some," and who ascribes the resulting uninsurance to people not wanting coverage.

Florida — 442,785 people, the biggest loss in America

Florida's −10% looks mild next to Ohio's −32%. Don't be fooled by the percentage. Florida's marketplace is enormous — 4.3 million people — so a 10% drop means 442,785 Floridians lost coverage, nearly three times as many as any other state on this list.

More Floridians depend on these credits than the residents of any other state in the country. 4.7 million of them.

That number is why the two Florida members below matter more than their percentage suggests.

Ashley Moody

Ashley Moody was one of the senators who blocked the extension. On December 11, 2025, she voted against even taking up a three-year extension of the ACA premium tax credits. The motion drew 51 votes — nine short of the 60 needed to advance.

She cast that vote knowing 4.7 million of her own constituents rely on those credits.

It isn't a new position for her. As Florida's Attorney General, Moody kept the state in the lawsuit seeking to strike down the entire Affordable Care Act — a position she maintained in May 2020, in the middle of the COVID pandemic, with more than a million Floridians having filed unemployment claims since mid-March.

First she tried to have the law struck down in court. Then, in the Senate, she voted to let the part holding premiums down expire. The method changed; the outcome she was working toward did not.

Gus Bilirakis

Gus Bilirakis voted yes on the House bill. He has been in Congress 19 years, chairs the Energy and Commerce Subcommittee on Commerce, Manufacturing and Trade, and sits on that committee's Health Subcommittee — the panel with jurisdiction over much of federal health policy.

His donor list is where this gets uncomfortable. Among his largest backers: GuideWell, the parent company of Florida Blue — $32,500. Florida Blue is the dominant insurer on the very ACA marketplace that just shed 442,785 customers. BioMarin Pharmaceutical gave $32,500 more, from a drugmaker whose approvals and pricing run through his Health Subcommittee.

The state-level forecast was published well before the vote. An estimated 990,000 Floridians will lose Medicaid coverage under the budget bill — rising to 1.5 million once the ACA marketplace subsidy cuts are counted, which would push Florida's uninsured rate from a historic low of 10.7% back up to 16.7%.

A member on the Health Subcommittee, funded by the health industry, representing the state with the most to lose, voted for it.

Texas — the thinnest safety net in America, cut anyway

Texas lost 146,345 people — a 4% drop that sounds small and isn't, because of where it landed.

Texas already had the highest uninsured rate in the United States: 16.8%, more than double the national average of 8.2%, with roughly 5.1 million people uninsured, according to KFF. Texas is also one of the ten states that never expanded Medicaid.

That combination is what makes a "mild" percentage brutal. In a state with expanded Medicaid, some people who lose marketplace coverage land somewhere. In Texas, most of them land nowhere.

And the forecast was ugly before this vote: an estimated 1.7 million Texans will lose their health coverage under the budget bill, with Texas hospitals set to lose $39 billion in Medicaid funding over the next decade.

Every Texas Republican in the House voted for H.R. 6703. Two of them stand out.

Monica De La Cruz

Monica De La Cruz represents TX-15 in South Texas, and she sits on the Ways and Means Committee — the same committee Jason Smith chairs, the one with jurisdiction over the tax credits that expired.

Her own district is among the hardest hit in the country. An estimated 65,193 people in TX-15 are projected to lose health coverage — and note the split: 61,700 of them losing ACA marketplace coverage, against 3,493 losing Medicaid.

This is not a Medicaid story in her district. It is almost entirely a marketplace story — which is to say, it is almost entirely about the credits her own committee could have extended.

Ronny Jackson

Ronny Jackson is a doctor. He served as White House physician to three presidents before winning TX-13 in 2021.

He is the third clinician on this list, after a nurse practitioner in South Carolina and an OB-GYN in Kansas. All three voted the same way.

There is no version of a medical career that leaves you unaware of what happens when a patient's coverage lapses. You see it directly: the delayed scan, the rationed insulin, the condition that was manageable in March and is not in September. Jackson spent decades close enough to that to know.

He voted yes.

The through-line

Look at the vote counts again. The Senate blocked the extension by nine votes short of cloture. The House passed its substitute 216–211. Neither outcome was inevitable; a handful of members in either chamber could have changed it.

Then look at who these fourteen people are. This is not a list of backbenchers who got steamrolled:

• Jason Smith chairs Ways and Means, the committee that writes tax law — and these were tax credits. Monica De La Cruz sits on it too.
• Virginia Foxx chairs Rules, the committee that decides what reaches the floor at all.
• Lisa McClain is Conference Chair, fourth in House Republican leadership.
• Jim Jordan chairs Judiciary and founded the Freedom Caucus.
• Gus Bilirakis sits on the Energy and Commerce Health Subcommittee.
• Roger Marshall is a physician on the Senate health committee, and Ronny Jackson was White House physician to three presidents.
• Sheri Biggs is a nurse practitioner.

Four of them held the gavels or the leadership posts that control what the House votes on. Two sit on the committee that writes tax law, and two more on the health panels themselves. Three of them treat patients for a living. If any group in Congress had both the power and the knowledge to force a different result, it was these fourteen — and their states are the ones that lost the most.

And notice what the House actually passed. Not a repeal. A bill named "Lower Health Care Premiums for All Americans Act," which loosens rules on association health plans and does nothing about the credits whose expiration was about to raise premiums 58%. It exists so that members can say they voted to lower premiums.

Every member above can now go home and say exactly that. The 2.6 million people who lost coverage this year are the reason it isn't true.

We've documented what this looks like on the ground in Alabama, Wisconsin, Arkansas and Ohio, and the full national tally of both votes is here.

The credits are gone. The people are uninsured. The votes are on the record with names attached — and in 2026, so are the members who cast them.