Lost among the concerns about impending Medicaid cuts and the newly-released MAHA strategy, we have a huge issue running up on us: will the enhanced Affordable Care Act (ACA) premium tax credits be allowed to expire at the end of September (effectively ending support as of January 1, 2026)? If they are not extended, the effect on rural America would likely be severe and disproportionate, both for physical AND mental health.

How severe?  Nationally, allowing these credits to expire is expected to result in 4 million more uninsured individuals and dramatically lower ACA Marketplace participation – possibly by as much as 50% in rural states. This is particularly important in mental health care which depends heavily on coverage, particularly Marketplace and Medicaid plans, which offer protections and essential benefits needed for access.

Rural communities already face fewer insurer options, higher premiums, and low employer-sponsored coverage rates. Rural residents – such as self-employed individuals, small-business workers, and farmers – often lack employer insurance and live in states that did not expand Medicaid. Enhanced tax credits have been essential for their coverage. 
Losing them may drive up uninsurance rates and cut off access to mental health services.

Mental health diagnoses and treatment are common among Marketplace enrollees.

A KFF (formerly Kaiser Family Foundation) analysis estimates that if coverage declines as projected, more than 1 million more people with mental health diagnoses could become uninsured by 2034. Without insurance, rural residents – who often face clinic closures and provider shortages – will find it especially difficult to seek treatment.

There will also be higher premiums – a double-whammy in rural areas, which already face expensive baseline rates. Rural residents are projected to experience premium increases of around 107%, compared to 89% in urban areas – an additional 28% burden over what urban communities will face. Fewer enrollees make markets more vulnerable to instability and provider pullouts.

Financial strain remains a top obstacle to mental health care. Already, even among the insured, 43% of adults with fair or poor mental health said they skipped needed treatment due to cost. Losing subsidies would only hike these numbers, especially in lower-income rural households.

These impacts also come on top of challenges that rural America faces. Around 80% of rural areas are medically underserved, facing a dearth of psychiatric and mental health providers. Insurance is critical not just to afford care, but to keep existing facilities viable. Rising uncompensated care from uninsured patients poses a threat to rural clinics and telehealth networks.

In addition, compounded economic stress worsens mental health. Rural communities, already facing economic volatility, would feel added stress—not only from healthcare cost increases, but also from broader cuts such as to Medicaid. This squeeze affects both mental well-being and the ability to seek care.

Why does all this matter? Negative impacts on rural communities can reverberate across the country. You may not realize it, but regardless of where you live – a city, the suburbs, in the country – you depend upon the mental and physical wellness of the rural population. Through agriculture, ranching, aquaculture, and forestry, they grow or raise, process, and package the food that fills your grocery store shopping cart.

Make your voice heard. Congress needs to act on this by September 30, 2025!

Contact your U.S. Senators and Representatives to urge them to make this a priority and take action to prevent these necessary health benefits from lapsing.