What happened
Federal data released June 26, 2026, shows ACA marketplace enrollment fell from 21.8 million in February 2025 to 19.2 million in February 2026—a decline of 2.6 million people, or 12%, the steepest single-year drop since 2014. The drop followed the expiration of enhanced premium tax credits that had kept monthly payments low from 2021 through 2025; when they lapsed at the end of 2025, the average subsidized enrollee's cost jumped about 114%.
Why it matters
Research spanning decades shows that gaining health insurance coverage improves access to preventive care, reduces depression, nearly eliminates catastrophic medical bills, and can reduce mortality among older low-income adults by about 9%. Conversely, losing coverage makes care harder to get and afford, and even brief gaps can double emergency visits and hospitalizations in the first month for conditions manageable with regular care—such as diabetes complications, heart failure, and asthma.
What to watch
Health policy experts expect enrollment to decline further, to 16.5 million to 17.5 million by end of 2026. Insurers are requesting a typical premium increase of 14% for 2027, which would be the second year in a row with double-digit premium rises. The pattern also differed by state: HealthCare.gov (the federal enrollment website) saw an 18.7% average decline, while state-run exchanges saw only 6.3%.
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The expiration of the enhanced premium tax credits—enacted during the COVID-19 pandemic to make marketplace coverage more affordable—is the direct cause of the enrollment collapse. These subsidies had more than doubled marketplace enrollment between 2020 and 2024, but when they ended on December 31, 2025, the financial burden on enrollees became unsustainable. While the Trump administration attributed some of the decline to improper enrollments (citing 250,000 unauthorized enrollments canceled and 200,000 unauthorized plan switches identified in 2025), independent analysts and the evidence point to price as the dominant factor: by February 2026, only 83% of people who selected a marketplace plan had actually paid their premiums and kept coverage, down from 91% the previous year.
The enrollment decline was not uniform across the country. States using the federal HealthCare.gov enrollment website saw an 18.7% average decline, while states running their own exchanges saw only a 6.3% decline—suggesting that state-run marketplaces had more capacity to help consumers compare plans and access additional financial assistance. Health policy experts now project enrollment to slide further to between 16.5 million and 17.5 million by the end of 2026, with insurers already requesting premium increases of 14% for 2027.
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