Enrollment figures for the Affordable Care Act (ACA) have shown unexpected resilience this year, despite significant cuts to premium subsidies. However, the true impact of these changes on long-term coverage remains uncertain as costs continue to rise.
The 2026 open enrollment period for the ACA has been marked by significant political turmoil, including discussions in Congress regarding the extension of enhanced subsidies that were available during the Biden administration. These debates contributed to the longest government shutdown in history, drawing public attention to the escalating costs of healthcare and the broader issue of affordability.
The expiration of enhanced subsidies at the end of last year has led to increased costs for nearly all individuals purchasing ACA insurance. Many have experienced premium hikes that have doubled their previous payments, even as less generous subsidies remain available.
Experts had predicted a decline in ACA enrollment, which reached a record 24 million in 2025. Katherine Hempstead, a senior policy officer at the Robert Wood Johnson Foundation, noted, “When prices increase significantly, economic principles suggest that demand will decrease.”
Factors to Monitor Moving Forward
Initial enrollment figures are not definitive. In December 2024, the Congressional Budget Office warned that the lack of extended subsidies could lead to 2.2 million individuals losing their insurance in 2026, with additional losses projected in subsequent years. Analysts from Wakely Consulting Group have also estimated that millions may choose to forgo insurance this year.
Data released on January 28 revealed a decrease of approximately 1.2 million enrollments compared to the previous year across both the federal and state-operated marketplaces, totaling 23 million enrollees, including 3.4 million newcomers to ACA coverage.
Last year, enrollment figures stood at 24.2 million, with 3.9 million new sign-ups. However, these numbers require careful interpretation, as they reflect varying deadlines for different marketplaces. While the federal marketplace closed on January 15, many state-run exchanges continued enrollment until the end of January, leaving a gap in data that could obscure potential late surges in sign-ups or cancellations.
Moreover, the initial enrollment numbers combine new and existing policyholders, many of whom were automatically renewed for 2026. The true impact of these changes will not be apparent for weeks or months as it becomes clearer how many individuals are able to maintain their premium payments. Many may not have fully grasped the cost implications of their auto-renewals or may have hoped for an extension of subsidies from Congress.
Pat Kelly, executive director of Your Health Idaho, highlighted the uncertainty, stating, “Consumers may find the premiums unaffordable and cancel their plans, while insurers may also terminate coverage due to nonpayment.”
Variations in State Enrollment Trends
Distinct enrollment patterns are emerging across the 19 states and the District of Columbia that operate their own exchanges, with several providing more detailed data on sign-ups than the federal marketplace.
Overall, most states have seen a decrease in enrollment for 2026 compared to the previous year, with North Carolina experiencing the most significant drop at nearly 22%. Conversely, a few states, including New Mexico, Texas, California, and Maryland, along with the District of Columbia, reported increases in the number of individuals selecting ACA plans. New Mexico, in particular, utilized its own tax funds to completely offset the loss of federal subsidies, leading to a nearly 14% rise in plan selections.
The State Marketplace Network, representing 22 state marketplaces, expressed concern about the initial figures, noting an 83% increase in outright plan cancellations in Colorado and a quadrupling of disenrollments in Idaho. Virginia has also reported a doubling of cancellations. California has seen new enrollments decline by 32% compared to last year, while older individuals aged 55 to 64 and younger adults aged 26 to 34 in Pennsylvania are terminating their coverage at higher rates than other age groups.
Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority, stated, “We have drastically higher rates of people dropping their coverage,” citing a loss of 70,000 enrollees in the past two months among various demographics.
Final enrollment numbers released by Pennsylvania on February 9 revealed a 2% decrease from the previous year, masking a more significant issue as nearly 18% of enrollees dropped coverage entirely, particularly older and rural residents.
Some Republicans have attributed the decline to anti-fraud measures introduced during the Trump administration, despite some of these actions being paused by a federal court. Critics of the ACA have claimed that the previous enhanced subsidies led to unauthorized enrollments or plan-switching by brokers seeking commissions, although state-run marketplaces report little evidence of such issues.
Cost remains the primary reason cited by consumers for not returning to the marketplace, according to Mila Kofman, executive director of the DC Health Benefit Exchange Authority. “Half of those who dropped coverage are small-business owners,” she noted.
Shifts Toward Lower Premium Plans
Amid concerns over affordability, many existing customers are opting for lower-cost “bronze” plans that come with higher deductibles, rather than sticking with automatic renewals. In California, 73% of renewing members who switched plans moved to bronze, a significant increase from 27% the previous year. In Maine, bronze plans now account for nearly 60% of all purchased plans.
Consumers are clearly prioritizing lower monthly premiums, with some hoping to avoid hitting their deductibles. Bronze plans typically carry an average annual deductible of $7,500, and while they must cover certain preventive services without additional costs, most other services are only covered after the deductible is met.
This trend of high deductibles may deter patients from seeking necessary medical care, as noted by Hempstead. “People are frightened to use their care and may delay treatment until conditions worsen,” she explained, warning that healthcare providers are preparing for an influx of insured patients unable to afford their deductibles.
“Hospitals are anticipating an increase in charity care, which could negatively impact their finances and potentially lead to layoffs or service reductions,” she added.
