This year, more Americans than anticipated signed up for Affordable Care Act (ACA) health insurance plans, largely due to premium subsidies. However, it remains unclear how many will continue to find these plans affordable in the coming months.
This situation is part of a larger narrative concerning ACA’s open enrollment period for 2026, complicated by ongoing congressional discussions about whether to extend the more generous subsidies that the Biden administration had implemented. This debate continues against a backdrop of rising healthcare costs, which have caught the public’s attention.
The enhanced subsidy, which previously made coverage more affordable by reducing the percentage of household income people needed to pay for insurance, expired last year. Consequently, almost all individuals who obtained ACA coverage saw their costs rise, with some experiencing premium payments that more than doubled, despite still having access to less robust subsidies.
Experts had expected a decrease in ACA enrollment this year after it hit a record high of 24 million in 2025.
“Economics suggests that when the price of something increases significantly, many will either not buy it at all or reduce their purchases,” remarked Katherine Hempstead, the senior policy director at the Robert Wood Johnson Foundation.
Initial numbers are not final
The Congressional Budget Office has informed lawmakers that initial enrollment figures are not conclusive. In December 2024, it projected that without an extension for the enhanced subsidies, around 2.2 million individuals would lose their insurance in 2026, and that figure could grow subsequently.
Data released on January 28 indicated an overall increase in ACA enrollment year-over-year, although the federal healthcare.gov marketplace and state markets saw approximately 1.2 million fewer registrations. The total reached 23 million enrollees, including 3.4 million new sign-ups.
This time last year, there were about 24.2 million enrollees, including 3.9 million newcomers.
However, the situation is more complex than those initial numbers suggest. The data from the federal market was fixed on January 15, the last day of the public enrollment period, while states that manage their own marketplaces only reported figures up to January 10 or 11. This means the numbers might not capture enrollment spikes or drops that occurred in later days.
Additionally, the preliminary figures include both new ACA enrollees and existing customers, many of whom were automatically reenrolled for 2026, which adds another layer of uncertainty. Exact numbers won’t be available for weeks or even months, as it remains unclear how many people are actually paying their premiums. Some may have overlooked registration deadlines or were hoping Congress would reinstate the subsidies.
Experts estimate that the number of individuals losing insurance stems from full-year coverage projections, rather than from initial contracts. Pat Kelly, executive director of Idaho’s ACA marketplace, noted that consumers might ultimately decide they can’t afford their premiums and thus cancel their plans.
There are significant differences in state enrollment patterns.
Enrollment trends vary significantly across the 19 states (plus the District of Columbia) that run their own exchanges, with some providing more detailed data than others. Federal data indicates that enrollment across most states declined in 2026 compared to the previous year, particularly in North Carolina, which saw a nearly 22% drop.
In contrast, states like New Mexico, Texas, California, Maryland, and D.C. experienced increases in those choosing ACA plans, with New Mexico seeing the largest rise—almost 14%. It uniquely utilized its own tax revenues to fully counterbalance the loss of federal tax subsidies.
Meanwhile, other states, such as California and Colorado, have seen a surge in outright plan cancellations, raising concerns about broader patterns of disenrollment.
For new registrations in California, there was a 32% decline compared to the previous year. In Pennsylvania, the highest drop in enrollment is occurring among those aged 55 to 64 and young adults aged 26 to 34.
“We’re witnessing a notable increase in people dropping out of insurance,” stated Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority. “In just two months, we’ve lost 70,000 jobs.”
Final numbers from Pennsylvania indicate that enrollment is down about 2% from last year, with nearly 18% of enrollees canceling coverage, particularly among seniors and rural residents.
Some Republicans have highlighted anti-fraud efforts promoted during the Trump administration, but critics argue that these measures — some of which face legal challenges — overlook the complexities of enrollment declines. Many critics claim that millions may have been improperly enrolled due to previous incentives.
However, states with their own marketplaces report minimal to no incidents of fraudulent activities. Mila Coffman, executive director of the D.C. Health Benefits Exchange, emphasized that cost remains the principal factor deterring consumers from returning to the marketplace.
“Half of those dropping out are small business owners,” she noted. “These are not individuals committing fraud.”
Premiums are lower and deductibles are higher
Instead of remaining with auto-reenrollment, many existing customers in various states opted for more affordable “bronze” plans with higher deductibles compared to silver, gold, or platinum options. In California, for instance, 73% of renewing members who switched plans chose bronze, a significant increase from just 27% last year.
People are clearly assessing what fits their monthly budget and opting for lower premiums. “Some are even contemplating skipping the deductible altogether,” remarked Stacey Pogue, a senior fellow at Georgetown University.
Bronze plans typically feature an average deductible of $7,500. While they cover certain preventive services without additional costs, most other services require meeting the annual deductible first.
This high deductible situation may discourage individuals from seeking necessary medical care, leading to potential complications down the line, which concerns many experts.
“People are hesitant to prioritize their health,” Hempstead explained. “They may delay necessary care until conditions worsen.”
Healthcare providers brace for an uptick in cases where patients have insurance, but can’t afford to meet their deductibles. “It’s anticipated that hospitals will need to provide more charity care, which could severely impact their finances and result in layoffs,” she added.
