Physicians Brace for Expiration of ACA Tax Credits, Uninsured Fallout
By Amy Lynn Sorrel

In the face of expiring insurance subsidies that have helped cover millions of Texans, plus other federal changes impacting the Affordable Care Act (ACA) marketplace, physicians are bracing for an anticipated surge in the state’s uninsured rate and the churn that could affect their practices and patient care. 

Created by the 2021 budget bill known as the American Rescue Plan Act, the enhanced premium tax credits (EPTCs) boosted the amount of financial assistance available to purchase ACA marketplace plans by removing what was then referred to as a “subsidy cliff,” namely the income limit of 400% of the federal poverty level. The credits were extended under the 2022 Inflation Reduction Act budget bill, which set them to expire at the end of 2025. 

The 2025 One Big Beautiful Bill Act (OBBBA) budget bill did not address the EPTCs, which means congressional action would be necessary to extend them again, prompting a call from organized medicine for federal lawmakers to act. OBBBA also instituted additional ACA marketplace changes, such as shortened enrollment periods and stricter verification requirements, the impacts of which the Texas Medical Association also is tracking.  

An estimated 1.3 million Texans could lose coverage due to the combined effects of ACA marketplace changes under OBBBA and the expiration of the enhanced tax credits, according to KFF research.  

“With the enhanced tax credits, middle-income enrollees making above 400% of poverty currently have their out-of-pocket premium payments for a benchmark plan capped at 8.5% of their income. However, if the EPTCs are not renewed, these enrollees will experience a ‘double whammy’ – losing their eligibility for marketplace premium tax credits and facing the annual increases in the cost of a marketplace plan,” a KFF analysis states. 

Texas still carries the designation of having the highest rate of uninsured in the country at roughly 20%. 

“Physicians are definitely going to feel the effects of both the confusion and the drop of coverage for a lot of patients, especially during the transition, when people are not understanding exactly how this transition affects them,” said Marcial Oquendo Rincon, MD. The Dallas pediatrician chairs TMA’s Council on Socioeconomics, which is tracking the ACA impacts along with TMA’s Committee on Medicaid, CHIP, and the Uninsured.   

Texas’ statistics are further complicated by the fact that as one of 10 states that did not opt for Medicaid expansion – which allowed those below the 133% of the federal poverty level to sign up for Medicaid coverage – ACA health plans have provided a coverage option made more affordable by the tax credits, TMA analysts note.   

According to Rice University’s Baker Institute for Public Policy, nearly 4 million Texans opted for ACA health plans in 2025, with subsidies of $1.5 billion going out to 3.4 million Texans the year prior – 16% of all subsidy funds distributed nationwide. 

“Even individuals who are not eligible for [advanced premium tax credits] will be affected by the expiration of the enhanced APTCs, as the enhanced APTC drew healthier people into the insurance marketplaces, improving the risk pool and lowering premiums overall,” the American Medical Association also cautions in a Sept. 15 letter imploring Congress to act.  

TMA and dozens of state and national medical societies signed on to the letter as well, which points to a Congressional Budget Office letter projecting an additional 4.2 million people in the U.S. will become uninsured by 2034 should Congress allow the enhanced credits to expire.   

Consistent with other studies, AMA also expects millions more will face significant increases in annual premiums.  

“These enhanced credits have made health coverage more affordable for the more than 24 million Americans who purchased coverage through the health insurance marketplaces in 2025, including many who are older, live in rural areas, or operate small businesses,” the letter says, citing a Centers for Medicare & Medicaid Services report.    

In Texas, a study by Episcopal Health Foundation shows rural counties make up a significant portion of ACA enrollment.  

Dr. Oquendo, who operates a group of 18 clinics across the Dallas-Fort Worth Metroplex, notes that among the 90% of his patients on ACA health plans, many already have trouble navigating the health care system without the additional confusion the expiring credits might create.   

TMA staff also caution physician practices to be aware of nontraditional or alternative forms of insurance patients might utilize should they lose their ACA health plans.  

“I’m anticipating a transition of people who are not going to come back because they'’re going to either lose their coverage or they’re going to think twice about signing up when they were used to having no premium, and now they have to pay maybe even a couple hundred dollars of premium,” Dr. Oquendo said. “That might be a shock,” he added, predicting that an increase in uninsured patients might put more strain on emergency departments and urgent care centers.  

Continue to read Texas Medicine Today for updates on OBBBA’s projected impact on Texas physicians, and learn more about TMA’s federal key issues.