Five Million Americans Drop ACA Health Coverage in 2026 as Subsidies Expire and Premiums Double

The expiration of enhanced premium tax credits has triggered one of the sharpest single-year drops in Affordable Care Act (ACA) enrollment in the program's history. According to federal data released on June 26, 2026, five million fewer people are currently enrolled in ACA marketplace plans for 2026 compared to the record high reached the prior year. The federal government's report indicated that 19.2 million people still hold ACA insurance in 2026.

The drop breaks down into two components: more than one million fewer people selected a plan for 2026 during open enrollment, and roughly four million additional people either actively disenrolled or lost coverage after failing to pay their premiums. The primary driver, according to health policy experts, is cost. After Congress allowed the enhanced premium tax credits to expire — Democrats had attempted to negotiate a three-year extension during a government shutdown in October 2025 — average marketplace premiums roughly doubled from 2025 to 2026.

The Trump administration has attributed part of the enrollment decline to fraud in the marketplaces. However, health policy researchers, including analysts at KFF and the Georgetown Center on Health Insurance Reforms, argue that while fraud exists in all insurance markets, it cannot account for a drop of this magnitude — the steep premium increases are the more plausible explanation. Notably, more than half of ACA enrollees live in Republican congressional districts, according to KFF.

The enrollment decline poses a structural risk to the marketplaces. Several insurers, including Cigna, have announced they will not participate in ACA markets in the coming year, citing a shrinking and less profitable customer base. A particular concern is adverse selection: the people dropping coverage tend to be healthier individuals, which raises the average cost of the remaining risk pool. If too many healthy enrollees exit, markets could theoretically enter a 'death spiral' of rising premiums and shrinking enrollment — though experts note that with roughly 19 million people still enrolled, the markets remain functional for now. For affected consumers, the higher costs have forced difficult decisions about family budgets and employment in an economy already strained by broader inflation.