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If Republican leaders in Congress refuse to extend the enhanced premium tax credit (PTC), millions of women and LGBTQ+ people will lose access to affordable Marketplace insurance, jeopardizing their health and economic security. It is imperative that Congress extend the enhanced PTCs and continue to protect access to health care coverage for women and LGBTQ+ people.
Enhanced Premium Tax Credits Are Critical for Women and LGBTQ+ People.
For the past decade, PTCs under the Affordable Care Act (ACA) have made Marketplace coverage affordable for women and LGBTQ+ people with low and moderate incomes by reducing the amount of their monthly health insurance premiums. PTCs allow women and LGBTQ+ people to access comprehensive and non-discriminatory health benefits, including reproductive care, preventive screenings, and other health care services vital to their health.
Premium tax credits were originally available to those with household incomes between 100 and 400% of the Federal Poverty Level (FPL)—for example, between $21,330 and $85,320 for a household of three in 2020.1 PTC recipients were required to contribute between 2 and 9.8% of their income towards annual premiums—a maximum contribution of about $400 of a $21,330 income and $8,344 of a $85,320 income.
During the COVID-19 pandemic, the American Rescue Plan Act of 2021 (ARPA) set the 2022 premium contributions to 0% for those with incomes between 100 and 150% of FPL (allowing for zero-premium coverage) and capped contributions at 8.5%. ARPA also expanded PTC eligibility to more households. Instead of limiting eligibility to households under 400%, ARPA considers whether households have access to alternative sources of affordable coverage, such as employer-based coverage with annual premiums less than 9.5% of a household’s income. For example, a household of three with an income of $88,000 (more than 400% of FPL in 2022),2 struggling to pay $12,000 in annual premiums (13.6%) for employer-based coverage, became eligible for PTCs—saving over $4,000 a year. This change also helped households without employer-based coverage, such as families juggling part-time jobs, secure PTCs regardless of income. The Inflation Reduction Act of 2022 extended enhanced PTCs through 2025.
As health care costs and premiums continue to rise,3 affordability measures, such as enhanced PTCs, are necessary to protect access to health care coverage for women and LGBTQ+ people.
PTCs reduced the share of uninsured women and LGBTQ+ people.
Cost is a primary barrier to health insurance. Women with lower incomes are at a greater risk of being uninsured,4 and a majority uninsured adults cite high costs of coverage for why they are uninsured.5 Because women, particularly women of color, and LGBTQ+ people are more likely to have lower incomes due to gender and racial pay discrimination and overrepresentation in low-paid jobs,6 large shares of women and LGBTQ+ people rely on PTCs to provide critical access to affordable coverage. Indeed, PTCs have aided in significantly reducing the share of uninsured women and LGBTQ+ people.
In 2014, over 9 million women, who otherwise lacked access to affordable health insurance, were eligible to benefit from the newly established PTC, including a disproportionate number of women of color.7 Tax credits, along with other provisions of the ACA, helped increase insurance coverage rates,8 and the share of uninsured women and girls decreased from 12.3% in 20139 to 7.6% in 2020.10 Rates of uninsured LGB+11 people also decreased from 17.4% in 2013 to 12.7% in 2019.12
When the enhanced PTCs were enacted in 2021, an estimated 4.1 million uninsured women, just of reproductive age, were eligible to benefit from the enhancements.13 And over 200,000 LGBTQ+ enrollees were eligible for zero-premium plans.14 The enhanced PTCs allowed most Marketplace enrollees to find quality health coverage for $10 or less.15
Under the first year of enhanced PTCs, women’s enrollment in the Marketplace increased by over 18% or 1.2 million—from 6.5 million in 2021 to nearly 7.8 million in 2022.16 The percentage of total Marketplace enrollees receiving PTCs also increased,17 with well over 6 million women in the Marketplace receiving PTCs in 2022.18 By the end of 2022, the share of uninsured women and girls reached a historic low of 6.8%.19
By 2024, women’s enrollment in the Marketplace grew to nearly 11.2 million20—a 72% increase from 2021. Furthermore, 92% of all 2024 Marketplace enrollees purchased coverage with PTCs,21 with approximately 10 million women receiving PTCs.22 Current rates of uninsured women and girls remain low,23 and the rate of uninsured LGBTQ+ people has decreased to 9% as of 2024.24
Ending the enhanced PTCs would harm women and LGBTQ+ people.
Ending the enhanced PTCs would reverse the historic progress made towards ensuring all women and LGBTQ+ people have health coverage and jeopardize the health and economic security of women and LGBTQ+ people.
If the enhanced PTCs end, millions of women would become uninsured.25 It is estimated that between 2.2 million26 and 4 million people27 will become uninsured, with Marketplace enrollments declining by over 7 million.28 Losing enhanced PTCs would be particularly devasting for women and LGBTQ+ people living in states without Medicaid expansion, disproportionately Black and Latinx,29 because enhanced PTCs provide access to zero-premium coverage for those with incomes between 100 percent to 150 percent FPL. Nearly 2.5 million people30 would suddenly lose access to zero-premium comprehensive coverage and face hundreds of dollars in premium spikes, all while having an income of less than $22,590 for an individual or less than $38,730 for a household of three.31
The expiration of enhanced PTCs will cause a steep rise in premiums and decrease insurance affordability for people of all ages and income levels, in every state.32 These premium increases would disproportionately impact women and LGBTQ+ people’s access to health care. With fewer financial resources, women are already more likely than men to forego or delay health care due to cost33 and nearly 1 out of 3 LGBTQ+ individuals report difficulty paying medical bills.34 If enhanced PTCs expire, the average premium would spike from $0 to $387 for those with incomes between 100 and 150 percent of FPL and from $180 to $905 for those with incomes between 150 and 200 percent of FPL.35 Increases for mid-life individuals, including women and LGBTQ+ adults ages 50 to 64, are projected to be even higher, with annual premium spikes between $599 and $4,574.36 Drastically higher premiums would exacerbate affordability issues, forcing women and LGBTQ+ people forego other necessities to pay for health care, take on medical debt, or go without coverage and care altogether.
If enhanced PTCs are ended, the health and financial wellbeing of women and LGBTQ+ people will inevitably suffer. Those whose coverage would be unaffordable, would be at risk of lengthy periods of uninsurance,37 worsening their health outcomes.38 Uninsured women and LGBTQ+ people are less likely than their insured counterparts to have regular care and to receive important preventive services, such as cancer screenings.39 And lack of regular care is especially harmful for women,40 particularly Black41 and Indigenous42 women, and LGBTQ+ people,43 who experience high rates of chronic conditions. Without health coverage, women and LGBTQ+ people may experience declines in their health, increasing the likelihood of medical debt, difficulty paying for necessities, and financial instability.44
Millions of women and LGBTQ+ people rely on enhanced PTCs to receive health care coverage. As women’s job recovery post-COVID-19 has lagged and many working women still struggle to make ends meet,45 it is vital to ensure access to affordable and comprehensive health coverage through the enhanced PTCs. To protect women and LGBTQ+ people’s health and financial wellbeing, enhanced PTCs must be preserved.
Find the official factsheet here.
Acknowledgements
This fact sheet was written by Airin Chen. The author would like to thank Dorianne Mason for their review and Kamilah Kerr for design.
Endnotes
1 Health Reform: Beyond the Basics, “Yearly Guidelines and Thresholds, Coverage Year 2020,” Ctr. on Budget & Pol’y Priorities (Aug. 2019), healthreformbeyondthebasics.org/wp-content/uploads/2019/10/REFERENCE-GUIDE_Yearly-Guideline-and-Thresholds_CoverageYear2020.pdf.
2 Health Reform: Beyond the Basics, “Yearly Guidelines and Thresholds, Coverage Year 2022,” Ctr. on Budget & Pol’y Priorities (Sep. 2021), https://www.healthreformbeyondthebasics.org/wp-content/uploads/2021/09/REFERENCE-GUIDE_Yearly-Guideline-and-Thresholds_CoverageYear2022-1.pdf.
3 Health Affairs, “Annual Family Premiums For Employer Coverage Rise 7% In 2024,” (Oct. 11, 2024),
10.1377/forefront.20241011.702725.
4 Kaiser Family Found., “Women’s Health Insurance Coverage,” (Dec. 12, 2024), https://www.kff.org/womens-health-policy/fact-sheet/womens health-insurance-coverage.
5 Jennifer Tolbert et al., “Key Facts About the Uninsured Population,” Kaiser Family Found. (Dec. 18, 2024), https://www.kff.org/uninsured/ issue-brief/key-facts-about-the-uninsured-population.
6 Jasmine Tucker & Julie Vogtman, “Low Wages, Unequal Pay, and Workplace Discrimination Rob Women and LGBTQIA+ People of Retirement Security,” Nat’l Women’s Law Ctr. (Mar. 2025), https://nwlc.org/wp-content/uploads/2025/03/final_2025_NWLC_LowWages.pdf.
7 Nat’l Women’s Law Ctr., “The Affordable Care Act Repeal Bill Would Put Affordable Health Coverage Out of Reach For Many Women,” (Mar. 2017), https://nwlc.org/wp-content/uploads/2017/03/Financial-Assistance-and-Repeal-FS-1.pdf.
8 Office Assistant Sec’y for Plan. & Evaluation, “Health Insurance Marketplaces: 10 Years of Affordable Private Plan Options,” U.S. Dep’t Health & Hum. Servs., 8-9 (2024), https://aspe.hhs.gov/sites/default/files/documents/d3a9870a7733cd75a67aec05698594d2/aspe-10-years-of-marketplace.pdf.
9 Nat’l Women’s Law Ctr., “NWLC Resources on Poverty, Income, and Health Insurance in 2023,” (Sep. 10, 2024), https://nwlc.org/resource/nwlc-resources-on-poverty-income-and-health-insurance/.
10 Nat’l Women’s Law Ctr., Press Release: “In 2021, more than 12 million women and girls lacked health insurance; poverty rates still adversely affected women of color at higher rates than their white counterparts; and the wage gap has for women overall widened to 84 cents.” (Sep. 13, 2022), https://nwlc.org/press-release/in-2021-more-than-12-million-women-and-girls-lacked-health-insurance-poverty-rates-still-adversely-affected-women-of-color-at-higher-rates-than-their-white-counterparts-and-the-wage-gap-has-for-wom/.
11 The available data does not include transgender individuals; therefore, LGB+ is used.
12 Office Assistant Sec’y for Plan. & Evaluation, “Health Insurance Coverage and Access to Care for LGBTQ+ Individuals: Current Trends and Key Challenges,” U.S. Dep’t Health & Hum. Servs., 4 (2021), https://aspe.hhs.gov/sites/default/files/2021-07/lgbt-health-ib.pdf.
13 Office Assistant Sec’y for Plan. & Evaluation, “Health Coverage for Women Under the Affordable Care Act,” U.S. Dep’t Health & Hum. Servs., 1 (2022), https://aspe.hhs.gov/sites/default/files/documents/a78c4d3d575d32cd09f7bf8db47e4812/aspe-womens-coverage-ib.pdf.
14 Office Assistant Sec’y for Plan. & Evaluation, supra note 12, at 7.
15 Office Assistant Sec’y for Plan. & Evaluation, “Healthcare Insurance Coverage, Affordability of Coverage, and Access to Care, 2021-2024,” U.S. Dep’t Health & Hum. Servs., 1 (2025), https://aspe.hhs.gov/sites/default/files/documents/9a943f1b8f8d3872fc3d82b02d0df466/coverage-access-2021-2024.pdf.
16 Kaiser Family Found., “Marketplace Plan Selections by Gender” Table for Timeframe: Open Enrollment 2021 – Open Enrollment 2022, https://www.kff.org/affordable-care-act/state-indicator/marketplace-plan-selections-by-gender-2.
17 Kaiser Family Found., “Marketplace Plan Selections with Financial Assistance” Table for Timeframe: Open Enrollment 2021 – Open Enrollment 2022, https://www.kff.org/affordable-care-act/state-indicator/marketplace-plan-selections-by-financial-assistance-status-2/.
18 NWLC calculation based on the number of women marketplace enrollees and the share of total marketplace enrollees that received APTCs. See id.; see also Kaiser Family Foundation, supra note 16-17.
19 Nat’l Women’s Law Ctr., supra note 9.
20 Kaiser Family Found., “Marketplace Plan Selections by Gender” Table for Timeframe: Open Enrollment 2024, https://www.kff.org/affordable-care-act/state-indicator/marketplace-plan-selections-by-gender-2/ (finding 11,157,905 women selected Marketplace plans and 21,446,150 total consumers selected Marketplace plans).
21 Kaiser Family Found., “Marketplace Plan Selections with Financial Assistance” Table for Timeframe: Open Enrollment 2024, https://www.kff.org/affordable-care-act/state-indicator/marketplace-plan-selections-by-financial-assistance-status-2/ (finding 19,743,689 consumers received APTC).
22 NWLC calculation based on the number of women marketplace enrollees and the share of total marketplace enrollees that received APTCs. See id.; see also Kaiser Family Foundation, supra note 20-21.
23 Nat’l Women’s Law Center, supra note 9.
24 Kaiser Family Found., “LGBTQ+ Health Policy: Health Coverage and Access,” Figure 9 (Sep. 30, 2024), https://www.kff.org/health-policy-101-lgbtq-health-policy/?entry=table-of-contents-health-coverage-and-access.
25 Estimations based 2022 research indicating that more than one million women would be uninsured if enhanced PTCs had expired in 2023. (Jessica Banthin et al., “Women’s Coverage Losses in 2023 If the American Rescue Plan Act’s Premium Tax Credits Expire,” Urban Inst. & Rober Wood Johnson Found., https://www.urban.org/sites/default/files/2022-07/Women%E2%80%99s%20Coverage%20Losses%20in%202023%20If%20the%20ARPA%20PTCs%20Expire.pdf). Since 2022, an additional 3.3 million women have enrolled in Marketplace coverage, likely increasing the number of women that would become uninsured if enhance PTCs expire in 2025. (See Kaiser Family Found., “Marketplace Plan Selections by Gender” Table for Timeframe: Open Enrollment 2022 – Open Enrollment 2024, https://www.kff.org/affordable-care-act/state-indicator/marketplace-plan-selections-by-gender-2).
26 Cong. Budget Off., “The Effects of Not Extending the Expanded Premium Tax Credits for the Number of Uninsured People and the Growth in Premiums,” 3 (Dec. 2024), https://www.cbo.gov/system/files/2024-12/59230-ARPA.pdf.
27 Jameson Carter et al., “Four Million People Will Lose Health Insurance If Premium Tax Credit Enhancements Expire in 2025,” Urban Inst. (No. 14, 2024), https://www.urban.org/urban-wire/four-million-people-will-lose-health-insurance-if-premium-tax-credit-enhancements-expire.
28 Id.
29 Id.
30 Id.
31 Health Reform: Beyond the Basics, “Yearly Guidelines and Thresholds, Coverage Year 2025,” Ctr. on Budget & Pol’y Priorities (Sep. 2024), https://www.healthreformbeyondthebasics.org/wp-content/uploads/2024/08/REFERENCE_YearlyGuidelines_CY2025.pdf.
32 Gideon Lukens & Elizabeth Zhang, “Premium Tax Credit Improvements Must Be Extended to Prevent Steep Rise in Health Care Costs,” Ctr. on Budget & Pol’y Priorities (Nov. 14, 2024), https://www.cbpp.org/research/health/premium-tax-credit-improvements-must-be-extended-to-prevent-steep-rise-in-health.
33 Lunna Lopes et al., “Americans’ Challenges with Health Care Costs,” Kaiser Family Found. (Mar. 1, 2024), https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/.
34 Lindsey Dawson et al., “LGBT+ People’s Health Status and Access to Care,” Kaiser Family Found. (Jun. 30, 2023), https://www.kff.org/report section/lgbt-peoples-health-status-and-access-to-care-issue-brief/.
35 Michael Simpson & Jessica Banthin, “Household Spending on Premiums Would Surge if Enhanced Premium Tax Credits Expire,” Urban Inst. & Robert Wood Johnson Found. (Dec. 2024), https://www.urban.org/sites/default/files/2024-12/Household-Spending-on-Premiums-Would-Surge-if-Enhanced-Premium-Tax-Credits-Expire.pdf.
36 Jane Sung and Olivia Dean, “Enhanced Premium Tax Credit Expiration Threatens Affordable Health Coverage for Nearly 5 Million Midlife Adults Ages 50 to 64,” AARP (Apr. 2025), https://www.aarp.org/content/dam/aarp/ppi/topics/health/coverage-access/enhanced-premium-tax-credit-expiration.doi.10.26419-2fppi.00363.001.pdf.
37 Liran Einav & Amy Finklestein, “The Risk of Losing Health Insurance in the United States Is Large, and Remained So After the Affordable Care Act,” 120 Economic Sciences e2222100120 (Apr. 24, 2023), https://doi.org/10.1073/pnas.2222100120.
38 See Jennifer Tolbert et al., supra note 5.
39 Kaiser Family Found., supra note 4; Lindsey Dawson et al., supra note 34.
40 Nat’l Acads. Sci, Eng’g, & Med., “Advancing Research on Chronic Conditions in Women,” (Sep. 25, 2024), https://www.ncbi.nlm.nih.gov/ books/NBK604853/.
41 Juanita J. Chinn et al., “Health Equity Among Black Women in the United States,” 30 J. Women’s Health 212 (2021), JWH-2020-8868-ver9-Chinn_3P 212..219.
42 Pamela Amparo et al., “Chronic Disease Risk Factors Among American Indian/Alaska Native Women of Reproductive Age,” CDC, Preventing Chronic Disease, Nov. 2011, at 1, https://pmc.ncbi.nlm.nih.gov/articles/PMC3221560/pdf/PCD86A118.pdf.
43 Lindsey Dawson et al., supra note 34.
44 See Jennifer Tolbert et al., supra note 5.
45 Sandra Markowitz, Jasmine Tucker, & Julie Vogtman, “The Recovery Paradox,” Nat’l Women’s Law Ctr., 7-8 (2024), https://nwlc.org/wp-content/uploads/2024/10/Final_The-Recovery-Paradox.pdf.