Nearly 5 million Americans have lost Affordable Care Act health insurance coverage in recent months, according to new federal data released this week showing a dramatic collapse in enrollment following the expiration of enhanced federal subsidies at the start of the year.
The enrollment declines paint a bleak picture for the nation’s primary insurance marketplace. Federal figures released in late June reveal that approximately 19.2 million people held ACA coverage in February 2026, down 3 million from the same period the previous year—a 13 percent drop that represents the steepest decline in the program’s history. Analysts project the enrollment losses could worsen substantially as 2026 unfolds, with some estimates suggesting the marketplace could fall to as low as 17.5 million enrollees by year’s end, a decline of roughly 5 million people from 2025 levels.
The primary culprit behind the enrollment collapse is clear: the expiration of temporary enhanced subsidies on January 1, 2026. These expanded tax credits, first enacted during the COVID-19 pandemic and extended multiple times by Congress, had dramatically lowered monthly premiums for most marketplace enrollees. Without them, millions of consumers faced sudden and severe premium increases that many could not absorb.
The impact has been uneven across states, with some experiencing particularly acute losses. North Carolina suffered the sharpest decline nationally, with enrollment plummeting 22 percent, or 214,000 fewer people. Ohio saw a 20 percent drop. Meanwhile, a handful of states bucked the national trend: New Mexico’s enrollment climbed 14 percent, while Texas, Maryland, California, and the District of Columbia all posted gains. New Mexico was unique in using its own tax dollars to fully replace the federal subsidies that expired.
For those who remained enrolled, the financial burden has intensified dramatically. Premiums for the average subsidized marketplace consumer more than doubled, surging from roughly $888 monthly in 2025 to approximately $1,904 in 2026. For many low-income families who had previously qualified for fully subsidized coverage under the enhanced credits, they now face premium payments for the first time. A 45-year-old earning $20,000 annually would see annual benchmark plan costs jump from $0 to $420. The situation is even more dire for middle-income earners and older adults, some of whom saw annual premium increases exceeding $22,000.
The federal Department of Health and Human Services attributed some of the enrollment decline to aggressive crackdowns on fraudulent enrollments, claiming to have blocked 2.9 million people receiving improper subsidies. However, health policy experts and analysts dispute this characterization, noting that the fraud explanation accounts for only a small fraction of the observed losses. Instead, most evidence points to people voluntarily dropping coverage because they simply cannot afford the higher costs, or failing to make their first premium payments after enrollment.
Internal government data obtained by news organizations revealed that approximately 21 percent of people who enrolled in healthcare.gov plans during open enrollment were subsequently dropped for failing to pay their initial premiums—nearly double the 12 percent dropout rate from the previous year. In states running their own exchanges, the picture was somewhat less dire, with roughly 8 percent of enrollees losing coverage through non-payment or voluntary cancellation between January and April.
Those who remained in the marketplace made difficult tradeoffs to manage costs. Enrollment in lower-tier bronze plans—which carry lower monthly premiums but substantially higher deductibles—surged from 7.3 million to 9.2 million people. The share of enrollees selecting cost-sharing reduction plans fell to an all-time low of 37 percent, with many eligible consumers instead opting for cheaper bronze coverage with deductibles often exceeding $10,000, despite being able to afford better coverage through cost-sharing assistance.
The demographic impact has been particularly severe for middle-income families. Nearly half of those earning more than 400 percent of the federal poverty level—roughly $64,000 for an individual or $131,000 for a family of four—fell into a “subsidy cliff,” losing all federal assistance while facing the steepest premium increases. Though representing just 7 percent of marketplace enrollees, this group accounted for 48 percent of the overall enrollment decline.
The expiration of the enhanced subsidies became one of the most contentious political issues in recent months. Democrats insisted that extending them should be tied to federal government funding, creating an impasse that led to a record-length government shutdown in the fall of 2025. Republicans ultimately blocked an extension, allowing the credits to expire as originally scheduled. The House later passed a three-year extension proposal with bipartisan support, but the legislation stalled in the Senate.
Insurance industry impacts have been severe as well. Major carriers including the Blue Cross Blue Shield Association, Centene, and UnitedHealth reported significant marketplace enrollment declines, while Cigna announced it would exit the ACA marketplaces entirely in 2027. Insurers have raised gross premiums by 26 percent on average for 2026, with industry filings indicating that 4 percentage points of that increase reflects expectations that healthier enrollees would abandon coverage as subsidies expired.
Analysts caution that the full extent of enrollment losses remains unclear, as data on “effectuated enrollment”—the number of people who actually pay premiums and maintain active coverage—won’t become fully available until later in the summer. Many consumers who were automatically re-enrolled in plans may ultimately stop paying premiums once they learn of the higher costs, meaning the real enrollment figures could be substantially lower than initial sign-up counts suggested.