By Elizabeth Schenkel, External Affairs Manager
There’s been a lot of noise lately about enhanced premium tax credits (PTCs) – what they are, who uses them, and what might happen if they expire. With headlines and opinions swirling, it can be difficult for partners and community members to get a clear picture of what’s what.
A Quick Refresher: What Are Enhanced Premium Tax Credits?
Premium Tax Credits are the financial assistance that lowers the cost of health insurance purchased through the Health Insurance Marketplace. Congress expanded (“enhanced”) these credits in 2021 so more people could afford coverage during a time of rising need.
These enhancements significantly increased the number of people who qualify for help and the dollar amount of help they receive. As a result, thousands of North Dakotans and South Dakotans have seen meaningful reductions in what they pay each month for coverage.
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What the Data Shows in ND and SD
With Enhanced PTCs, more Dakotans enrolled in Marketplace coverage than ever before. Improvements in affordability made coverage more accessible – especially for those making above 400% of the federal poverty level (FPL), who were previously ineligible for premium tax credits – and would be again if PTC enhancements expire. In 2020, before enhanced PTCs were available, about 21,000 North Dakotans and 41,000 South Dakotans enrolled in Marketplace coverage. In 2025, with enhanced PTCs available, nearly 43,000 North Dakotans and nearly 55,000 South Dakotans were enrolled – A big leap in coverage numbers. [Source: KFF]
Rural communities are especially impacted. As Marketplace participation increases, the overall insurance risk pool strengthens, which supports lower premiums statewide. In rural and frontier parts of ND and SD, where employer-based coverage is less common and distances to care are greater, these affordability improvements play a critical role in sustaining coverage. [Source: The Commonwealth Fund]
If Enhanced PTCs expire, KFF estimates that 26,000 people in ND and 20,000 people in SD may lose coverage due to unaffordability. It is expected that households with income above 400% FPL will be most likely to drop coverage because their increases will be the most stark. With fewer people covered by insurance and an unbalanced risk pool for insurance companies, health insurance costs could rise for everyone. Insurance companies will have to account for higher claims pay-out because healthy people will be the first to opt out of insurance. Health care providers would be at risk for higher uncompensated care costs and, to stay open, would have to bake those losses into the cost of care for us all – or risk closure, threatening access to care for the hundreds of thousands living in rural and frontier parts of the Dakotas.
The Human Side: Affordability Builds Stability
Enhanced PTCs don’t just lower premiums; they create stability in ways that ripple through families and communities:
- Families stay insured, ensuring children maintain consistent access to preventive care.
- Workers stay healthier, supporting productivity, small business growth, and community economic strength.
- Hospitals and clinics—especially rural facilities—benefit, because insured patients can receive routine and follow-up care, reducing uncompensated care and supporting the financial health of local providers.
- Emergency care costs go down, as people can manage conditions early rather than delaying care due to cost.
A Note from South Dakota Navigators
Navigators in South Dakota report something encouraging: even individuals who return to the Marketplace year after year—many of whom feared they might be “priced out” due to the potential expiration of enhanced PTCs, have been able to find plans within their budget for 2026 – especially those under 300% FPL.
Marketplace insurance help is available. Navigators and Certified Application Counselors across the Dakotas can help individuals and families:
- Understand plan options
- Estimate premium tax credits
- Compare plans
- Complete applications
- Upload verification documents
Help is free, local, and available. Find assistance at: getcoveredsouthdakota.org
Looking Ahead
Nonpartisan health organizations across the country, including Community Catalyst, are urging Congress to make these enhanced tax credits permanent so families and communities don’t lose the affordability gains of the last several years. For those who want to get involved, a petition is available to sign here.
