Nationwide enrollment in the Affordable Care Act (ACA) health insurance marketplace is projected to plummet by nearly 5 million people this year, representing a more than 20% reduction in participants, according to a new analysis from the healthcare research nonprofit KFF.
The report also indicates that those who maintain coverage are facing significantly higher costs.
The KFF analysis suggests ACA enrollment could fall from 22.3 million Americans in 2025 to approximately 17.5 million this year.
This stark decline, more severe than initial federal data indicated, highlights how escalating health costs are compelling Americans to make difficult mid-year decisions about their health coverage.
A primary driver of these rising costs is the expiration of federal subsidies on January 1, which previously helped the vast majority of enrollees afford their plans. This issue is expected to be a significant factor in this year’s midterm elections, where economic concerns are paramount in many competitive races.
For those who remain covered, the financial burden has increased substantially. The average enrollee’s deductible has grown by over $1,000, and the average monthly premium payment rising by $65.
Cynthia Cox, a vice president of KFF and co-author of the report, stated, “No matter how you slice it, people are paying more.”
A key reason for the substantial drop-off is that many Americans were automatically renewed into their plans from the previous year.
These plans often became far more expensive due to the expired subsidies and other market dynamics. When individuals can no longer afford the monthly fees, they lose their coverage, Cox explained.
The report found that middle-income Americans disproportionately dropped coverage.
This group earns too much to qualify for the remaining subsidies, which are reserved for low-income enrollees, but not enough to comfortably afford their health coverage without the enhanced COVID-era subsidies that have now expired.
ACA plans have become a popular choice for working-age Americans who do not qualify for Medicaid, including gig workers, farmers, ranchers, and hairstylists. While drops in ACA sign-ups were observed across most states, KFF noted that states operating their own exchanges retained a larger percentage of enrollees compared to those relying on the federal marketplace.
The Trump administration has asserted that federal efforts to combat fraud within the ACA program are largely responsible for this year’s enrollment declines. The Centers for Medicare and Medicaid Services (CMS), whose final 2026 enrollment data is not yet public, did not immediately respond to a request for comment on KFF’s report.
Last year, anticipating the expiration of the COVID-era subsidies, KFF had projected that premium payments would more than double in 2026.
The new analysis, however, found that premium payments jumped by a more modest 58 percent on average. This was partly because many individuals downgraded to lower-premium, higher-deductible plans, which will only cost them more if they utilize the coverage. “People are trying to hang on to their health insurance coverage any way they can, even if that means they have a deductible of $7,000,” Cox said.
Despite the current challenges, Cox expressed some optimism. She noted that insurers appear to have anticipated and already made adjustments for many of the marketplace changes currently unfolding. This could potentially mean that future health costs may not rise as sharply. “I’m hopeful that this could be a one-time market correction and that we might not need to see such a high premium spike in the coming year,” Cox concluded.