GOP Budget Bill Will Strand Millions of Rural Americans With Outrageous Health Insurance Premiums

Editor's Note: This post is from our data newsletter, the Rural Index, headed by Sarah Melotte, the Daily Yonder's data reporter. Subscribe to get a weekly map or graph straight to your inbox.

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In 2026, millions of rural Americans will see their health insurance premiums skyrocket – some by more than $1,300 per month – if Republicans win budget negotiations and end Biden-era insurance subsidies, according to my analysis of data from the Centers for Medicare & Medicaid Services (CMS).

The Senate version of Trump's budget reconciliation bill failed to garner enough votes to pass, resulting in a nearly month-long shutdown that began on October 1. At the crux of the bill's failure – and the reason why the government hasn't reopened – is whether to fund Biden-era health insurance subsidies included in the Inflation Reduction Act that are set to expire at the end of this year.

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The subsidies lower monthly premiums for consumers who obtain coverage through private health insurance marketplaces that were created by the Affordable Care Act (ACA) in 2014. These subsidies were meant to help people who don't qualify for Medicaid, are too young to receive Medicare, and whose employer doesn't offer a private health insurance plan.

If the GOP slashes funding for these subsidies, enrollees will be forced to either pay for the entire premium out of pocket, if they can afford it, or abandon health insurance altogether. In rural Tyler County, West Virginia, for example, the average monthly premium will increase by $1,339 in 2026. In rural Pope County, Illinois, the average monthly premium will increase by $1,258.

More than 2.2 million rural Americans – and 13.8 million urban and suburban Americans – will see their health insurance premiums increase if the GOP wins negotiations during the government shutdown.

This data comes from the Centers for Medicare and Medicaid (CMS), which aggregates data at the state, county, and ZIP code levels. This dataset only includes the 31 states that use the federal Healthcare.gov health insurance marketplace to enroll consumers. The figures in this analysis are from the 2025 Open Enrollment Period (OEP), which ran from November 1, 2024, to January 15, 2025.

Originally, the health insurance subsidies were available to consumers with incomes between 100% and 400% of the Federal Poverty Level (FPL), roughly $32,000 to $128,000 for a family of four. But the American Rescue Plan Act of 2021 expanded those subsidies to Americans living above 400% of the FPL, and the Inflation Reduction Act extended those subsidies until the end of 2025. Under the ACA, monthly premiums are capped based on income, with the federal government covering the remaining cost.

Compared to their urban counterparts, rural Americans are more likely to live in counties that will see the highest monthly health insurance premium spikes.

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Nearly a quarter of rural Americans live in a county where the average premium increase will be between $659 and $1,339 per month. Only 2% of urban and suburban residents live in counties that will see this level of increase, meanwhile. On the other hand, 41% of metropolitan residents live in counties that will see the lowest increase in premiums – less than $509 per month. Only 18% of rural Americans live in counties in that category, however.

Rural West Virginia will see some of the highest premium spikes in the nation. All 35 of West Virginia's nonmetropolitan, or rural, counties are in the fourth quartile of the highest premium spikes. In 33 of those 35 rural counties, the average premium increase will be more than $1,000 per month.

According to the Center on Budget and Policy, 15,000 West Virginians who have health insurance through the marketplace will lose health insurance altogether in 2026, if the current health insurance subsidies are not renewed.

Any increase in health insurance premiums is likely to result in loss of coverage for many Americans. One study found that, for every $40 increase in monthly premiums, there was a corresponding drop of one-fourth of the low-income enrollee population. Surveys find that cost is the main reason people don't sign up for health insurance. According to the Congressional Budget Office, expiring subsidies will lead to 4.2 million enrollees losing health insurance by 2034. The end of these subsidies will hurt Americans across the board, regardless of whether they live in a rural or urban area.

Despite the partisan divide in Washington, funding for these subsidies has broad popular approval. A KFF Health News poll found that 78% of Americans believe that Congress should extend marketplace subsidies. In Florida, for example, conservatives have initiated a letter-writing campaign urging their legislators to extend health care subsidies.

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