Enrollment in the Affordable Care Act (ACA) health insurance marketplace is projected to decrease significantly, with an estimated drop of nearly 5 million participants this year, according to a recent analysis by the healthcare research nonprofit KFF. This decline represents more than a 20% contraction in the program, which has long served as a crucial safety net for Americans who do not qualify for Medicaid.
The analysis indicates that those who continue to maintain their coverage are facing higher costs than in previous years. The average enrollee’s deductible has increased by more than $1,000, while monthly premium payments have risen by $65. Cynthia Cox, a vice president at KFF, emphasized the burden on enrollees, stating, “No matter how you slice it, people are paying more.”
This expected decline in enrollment is attributed largely to the expiration of COVID-era subsidies at the start of the year, which had helped many enrollees afford their plans. As a result, Americans are now grappling with tough choices about whether to keep their health coverage or forgo it altogether. This issue is likely to resonate in the upcoming midterm elections, particularly as economic concerns take center stage in competitive races nationwide.
KFF’s report estimates that ACA enrollment could fall from 22.3 million in 2025 to approximately 17.5 million this year, utilizing data from federal and state resources as well as insights from the actuarial firm Wakely Consulting Group. The ACA has been particularly popular among gig workers, farmers, and other professionals who do not receive health insurance through their employers.
The sharp decline can be partially attributed to the auto-renewal of many plans from the previous year, which are now significantly costlier due to the expired subsidies. Many individuals who find themselves unable to keep up with payments during the year ultimately lose their coverage. The report highlights that middle-income Americans have been disproportionately affected by this trend, as they exceed income thresholds for the remaining subsidies designed for low-income enrollees but struggle to afford health insurance without the enhanced support that has now lapsed.
The analysis found enrollment drops across most states, though those with individual exchanges retained a higher percentage of enrollees than those relying solely on the federal marketplace. The Trump administration has attributed the drop-offs to efforts aimed at combating fraud within the ACA program, while the Centers for Medicare and Medicaid Services has yet to release its final enrollment figures for 2026.
For those who remain enrolled in the marketplace, costs are steep. Although KFF had originally predicted that premium payments would more than double by 2026, the actual increase has been about 58% on average. Many enrollees have opted for lower-premium, higher-deductible plans, which can lead to more extensive out-of-pocket costs if medical services are utilized. Cox noted, “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.”
Caitlin McElroy, a 38-year-old from Orlando, has experienced a spike in her premium from $32 to $89 per month. Despite her financial constraints, she relies on coverage for managing Crohn’s disease and her mental health, forcing her to make sacrifices, such as delaying utility payments and cutting fresh produce from her diet.
Despite the challenges, there may be a glimmer of hope. Cox suggested that insurance companies have perhaps anticipated these market changes and made adjustments, which could mitigate future cost increases. “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,” she said.
