Affordable Care Act Enrollment and Cost Shifts in 2026

The Affordable Care Act saw enrollment slip and consumer costs climb in 2026 after expanded federal subsidies ended, reshaping U.S. health coverage.

Key takeaways

• Enrollment fell sharply: ACA marketplace enrollment dropped around 5% early in 2026 and may fall from about 22.3 million in 2025 to roughly 17.5 million in 2026. (KFF)
• Costs spiked: The average deductible in ACA plans rose by over $1,000 and average monthly premiums increased significantly after enhanced tax credits expired. (KFF)
• Policy shifts are accelerating change: New rules finalized by the Centers for Medicare & Medicaid Services (CMS) will expand access to high‑deductible catastrophic plans and relax plan requirements starting in 2027. (Healthcare Dive)
• State differences matter: Some states like Texas saw enrollment increases due to state subsidies and market strategies, while others saw steep drops. (Houston Chronicle)

What the Affordable Care Act is and why 2026 feels different

The Affordable Care Act (ACA) is the landmark U.S. health reform law signed in 2010 that created regulated health insurance marketplaces, required essential benefits, and barred insurers from denying coverage for preexisting conditions. (LegalClarity)

For much of the early 2020s, enhanced premium tax credits introduced during the pandemic made marketplace coverage far more affordable for millions. Those enhancements expired at the end of 2025, meaning enrollees now face higher premiums and deductibles in 2026. (KFF)

This shift is not academic. Preliminary data show that in January 2026 there were about 1.2 million fewer ACA enrollees than last year, with many people unable to keep up with rising costs. (KFF Health News)

Enrollment declines: how many people are losing coverage?

Enrollment in ACA plans is declining meaningfully in 2026 after years of growth. Early enrollee totals dipped by about 5% year over year in the first months of the year. (KFF)

Analysts project total enrollee numbers could shrink from roughly 22.3 million in 2025 to 17.5 million in 2026 — a drop of nearly 5 million people if trends continue. (NBC Bay Area)

State data echo these national patterns. States like Kentucky and Idaho recorded sharp disenrollment increases tied to non‑payment of premiums. (Reuters)

However, not all states follow the same script. Texas, for instance, reported a 5% increase in ACA sign‑ups early in 2026 after deploying state‑level policies to keep premiums stable. (Houston Chronicle)

Rising costs and plan changes

Without enhanced subsidies, marketplace costs rose fast in 2026. According to the latest research:

• Average monthly premiums climbed noticeably for many enrollees as subsidies shrank. (Managed Healthcare Executive)
• Deductibles jumped by more than $1,000 on average — one of the largest single‑year increases since the ACA’s inception. (KFF)
• More consumers are shifting to lower‑premium, higher‑deductible plans such as bronze or catastrophic plans. (Healthcare Dive)

These trends feed a cycle: higher costs lead to unpaid premiums and further disenrollment, which in turn can push insurers to raise rates again. (KFF Health News)

Policy changes shaping the ACA’s future

CMS has finalized substantial marketplace rule changes that could reshape ACA coverage beyond 2026. Among the notable adjustments:

• Expanded access to catastrophic plans: More enrollees can choose high‑deductible, lower‑premium plans starting in 2027. (Healthcare Dive)
• Relaxed standardized plan requirements: Insurers will have more flexibility in plan design, which may lead to wider variation in coverage quality. (Becker's Payer Issues | Payer News)

Proponents say these changes aim to lower upfront costs; critics warn they could weaken consumer protections and increase out‑of‑pocket expenses when care is needed. (STAT)

States, politics, and the subsidy cliff

Federal policy isn’t the only force. States that supplement federal subsidies or market design — like California and Massachusetts — are better positioned to sustain enrollment. Others without state support face steeper coverage losses. (Covered California)

Political gridlock in Congress has prevented a long‑term extension of enhanced tax credits that previously kept many premiums affordable, leaving the ACA in a cost‑sensitive phase. (PBS)

FAQ

What is the Affordable Care Act?

The Affordable Care Act is a federal U.S. law that set insurance standards, created health insurance marketplaces, and expanded access to coverage with subsidies and consumer protections.

Why is ACA enrollment declining in 2026?

Enrollment is declining largely because enhanced federal premium tax credits that lowered costs expired at the end of 2025, making coverage more expensive for many enrollees.

How have costs changed under the ACA in 2026?

In 2026, marketplace deductibles increased by over $1,000 and premiums rose significantly as enhanced subsidy levels ended and cost‑sharing protections diminished.

Sources

• What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles. KFF. 2026‑05‑19.
• Americans are dropping out of Obamacare, especially in Kentucky. Reuters. 2026‑05‑28.
• CMS finalizes ACA marketplace overhaul for 2027: 6 notes. Becker’s Payer Issues. 2026‑05‑18.