More than one million Texans could lose Affordable Care Act (ACA) health insurance next year if federal subsidies expire. That’s one of the findings of a new study from researchers at the Bush School of Government & Public Service at Texas A&M University and funded by Episcopal Health Foundation.
The report finds that if federal subsidies end in December 2025, between 665,000 and 1.45 million Texans could lose their ACA health insurance coverage because of higher costs. As a result, up to 800,000 Texans would end up uninsured, wiping out the record gains made when COVID-era subsidies lowered ACA premiums for millions.
“Taking away these subsidies would create serious new barriers for Texans trying to stay healthy,” says Dr. Ann Barnes, Episcopal Health Foundation’s president and CEO. “It could push our uninsured rate back up to 20%, wiping out years of progress and leaving families without affordable options for health insurance.”
Since 2021, expanded federal subsidies have lowered monthly premium costs for 95% of Texans with ACA coverage, helping drive record enrollment of nearly 4 million people in 2025. Without those subsidies, premiums could double or more, and many middle-income families would lose all financial help.
“If these subsidies expire, many more Texans will become uninsured, putting added strain on hospitals that already care for so many patients without health insurance,” says Laura Dague, James M. Griffin Professor of Health Policy at the Bush School of Government and Public Service at Texas A&M University and one of the authors of the report.
The results of their research are summarized in the latest issue of The Takeaway, Expiring Subsidies Threaten Texans’ Health Insurance Gains. The full report includes county-level data on projected ACA enrollment declines and uninsured rates.
County by County Impact
In addition to the report, Episcopal Health Foundation released a new interactive map (below) that shows, county by county, how many Texans have ACA health insurance and how much federal subsidies lower their monthly premiums on average. The map also uses data from the Bush School report to project the uninsured rate in 2026 in each county if federal subsidies expire.
On average, around 11% of the population in the state’s largest urban counties (Harris, Dallas, Bexar, Tarrant, and Travis) is enrolled in ACA plans. Harris County alone has nearly 690,000 people covered through the ACA. Dallas County has more than 318,000, and Bexar County has more than 234,000.
In South Texas, the impact is especially clear. In Starr County, more than one in four residents has ACA coverage, while in Maverick and Hidalgo counties it is more than one in five. In each of these counties, subsidies now cover more than 95% of the average premium cost, making insurance affordable for families who might otherwise go without it.
East Texas shows a similar pattern. In Polk and San Jacinto counties, about 18% of residents have ACA coverage, while in Gregg County it is 15% and in Angelina County it is 13%. In each of these areas, subsidies currently cover more than 95% of average premiums, underscoring how essential this support is for keeping health insurance affordable.
How EHF is Taking Action
EHF is working with ACA enrollment organizations across the state to prepare communities for possible changes and to help families navigate coverage options during the upcoming open enrollment period. Many of these organizations face budget shortfalls following federal funding cuts for enrollment outreach, leaving them with fewer staff to assist the millions of Texans who need guidance.
To keep navigators in place and outreach going, EHF’s board has approved up to $1 million in grants for organizations that help families with the biggest barriers to care get covered.
“Congress needs to consider changes so Texans don’t lose the gains we’ve made in helping increase access to prevention, chronic disease management, and important screenings,” Barnes says. “This is a moment that shows how connected policy decisions are to people’s everyday health. When coverage becomes unaffordable, families and communities immediately feel the impact.”