The Honorable Mike Johnson
Speaker, U.S. House of Representatives
Washington, D.C. 20515
The Honorable John Thune
Majority Leader, U.S. Senate
Washington, D.C. 20515
The Honorable Hakeem Jeffries
Minority Leader, U.S. House of Representatives
Washington, D.C. 20515
The Honorable Charles Schumer
Minority Leader, U.S. Senate
Washington, D.C. 20515
Speaker Johnson, Leader Jeffries, Leader Thune, Leader Schumer, and North Carolina’s
congressional delegation:
With major health care changes ahead, I write to urge Congress to quickly extend the Affordable
Care Act’s (ACA) enhanced premium tax credits by September 30, 2025, to prevent costs from
skyrocketing for hundreds of thousands of North Carolinians. In North Carolina, more than
924,000 people get health insurance through the Affordable Care Act (ACA) Marketplace. This
includes farmers, small business owners, independent contractors, gig workers, families whose
employers do not offer insurance, and many others who contribute to our economy.
North Carolinians who get their health insurance through Marketplace plans will soon start
receiving letters from their insurance companies announcing significant increases in their 2026
monthly premiums. Though enhanced premium tax credits expire on December 31, 2025,
Congress must extend ACA enhanced tax credits by September 30, 2025, in order to avoid
customer confusion and coverage losses before Open Enrollment in November. If Congress waits
until December 31, regulators and health plans will not have time to adjust their rates before
January 1, 2026 – and it will be too late for many people to opt into affordable health insurance.
Enhanced premium tax credits, which began in 2021 and were extended in 2022, have helped the
vast majority of North Carolina Marketplace enrollees (about 888,000 people, or 96% of
Marketplace enrollees) afford monthly health insurance premiums. Nearly 80% of enrollees were
able to find plans that would cost $10 or less per month with the enhanced premium tax credits in
2023-2024, compared with only 36% able to find such plans without the help of enhanced
premium tax credits in 2020.
If Congress does not extend the enhanced premium tax credits, these 888,000 individuals will
have their out-of-pocket premiums double on average starting in January 2026. For about
157,000 North Carolinians, these out-of-pocket premium increases will mean they will be unable
to afford health insurance altogether and will become uninsured, raising costs for everyone. If the
enhanced premium tax credits expire, the average Marketplace enrollee in North Carolina is
expected to pay $672 more per year for the same health insurance. Rural residents will be hit
even harder, paying $703 more per year. In rural eastern and western North Carolina, the
counties of Dare, Hyde, Brunswick, Pamlico, and Transylvania would face the highest average
loss of premium tax credits, paying more than $1,000 more per year.
Unfortunately, the people who will be hit the hardest across the nation are those who can least
afford to lose their health insurance. People who enrolled in the Marketplace with the lowest
incomes would see the greatest percentage increases in their annual premiums. For example,
annual premiums for a 45-year-old person with an annual income of $25,000, or 166% of the
federal poverty level, would rise an average of 573%, or $917, for a benchmark silver plan. This
means the annual premium payment would increase from $160 to $1,077. Younger people ages
19 to 34 are most likely to become uninsured due to expiration of premium tax credits.
Too many North Carolinians risk either being priced out of health insurance entirely or paying
exorbitant costs to continue to get essential health coverage. The small percentage of North
Carolinians who purchase health insurance on the Marketplaces without premium tax credits are
not spared either. The NC Department of Insurance announced on July 31, 2025, that insurers
participating in the individual market have requested rate increases with a weighted average 29%
increase amid a range of 6.9% to 36.4%. These are the highest rate increases since 2016. Insurers
have stated that they are raising rates due to health care inflation, the possible expiration of
enhanced premium tax credits, and changes to the Marketplace as a result of the federal
reconciliation law and the Marketplace Integrity and Affordability Final Rule.
The NC Department of Insurance has indicated the expiration of premium tax credits “will make
it more difficult for people to afford their premiums.” The Department of Insurance also said that
“many people will become uninsured” and “more healthy and younger people are expected to
drop their coverages, leaving the pool more costly.”
When younger, healthier people exit the marketplace, costs increase for everyone. It also creates
a more volatile and untenable market for insurers, and there are concerns that more insurers
would pull out of the individual market altogether. While nine insurance companies offered
individual/family health plans through North Carolina’s marketplace in 2025, two have already
stated they plan to exit the market by the end of 2025, limiting options for North Carolinians.
Due to the reconciliation law, North Carolina’s health care system is already under extreme
pressure; we cannot face even more people losing their insurance. Loss of insurance would put
family finances and health in peril; increase costs for everyone, including those who get private
or commercial insurance from their employers; drive up medical debt; and leave hospitals and
providers on the hook for more uncompensated care. People won’t simply stop getting sick.
Their health care will just become more costly. Changes in the insurance market will have ripple
effects, resulting in higher health insurance costs for everyone.
We have a responsibility to stay laser-focused on lowering costs for families, including by
driving down health care costs. We cannot stand by as health care costs skyrocket for families
across North Carolina and the country, and I urge you to do your part and take swift action to
extend the enhanced premium tax credits.
Sincerely,
Josh Stein
Governor
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