Affordable Care Act enrollment could drop by nearly 6 million in 2026, report warns — Here's why

Average monthly enrollment in the Affordable Care Act (ACA) marketplace is expected to drop sharply in 2026 after enhanced federal tax credits that helped drive record coverage levels in recent years expire.

According to estimates based on data from the Wakely Consulting Group and federal Marketplace reports, average actual enrollment — referring to consumers who actually pay premiums and maintain active coverage — could drop to about 17.5 million in 2026, from 22.3 million in 2025. In a worst-case scenario, the number could drop to as low as 16.5 million.

That would mean a drop of 17% to 26%, or about 3.8 million to 5.8 million fewer insured Americans than last year.

Steepest Enrollment Drop Since ACA Launched

Open enrollments fell by more than one million people to 23.1 million during the 2026 period, the steepest one-year decline since the launch of the ACA Marketplaces.

But analysts caution that the selection of plans doesn’t fully reflect actual coverage because many consumers don’t pay premiums after signing up. Wakely Consulting estimates that in 2026, only about 86% of January students paid their first month’s premium.

Federal analysts and insurers expect more coverage losses later in the year as rising premiums force more consumers to drop plans or miss payments.

The end of increased tax relief is leading to an affordability crisis

The sharp decline follows the expiration of extended tax credits introduced under the US bailout plan in 2021 and extended until 2025 by the Inflation Reduction Act.

These subsidies extended financial assistance to millions of middle-income Americans and, for many households, capped matching premiums at 8.5% of income.

Without these increased subsidies, average monthly premium payments would have increased dramatically in 2026. Consumers now pay an average of $178 a month after subsidies, up 58% from $113 in 2025.

Analysts said the increase would have been even larger if many consumers had not switched to cheaper plans with higher deductibles.

Consumers above the subsidy cliff were the most affected

The report found that Americans earning just above the subsidy eligibility threshold were disproportionately affected.

Consumers with incomes between 400% and 500% of the federal poverty level accounted for only 3% of Marketplace enrollments in 2025, but accounted for 27% of the total decline in coverage in 2026.

Plan selection in this group fell by 44%, or more than 321,000 people.

Overall, consumers above the so-called “subsidy cliff” accounted for nearly half of the decline in Marketplace signups, despite being a relatively small share of total signups.

Deductions jump to record highs

As premiums rose, many consumers switched from silver plans to cheaper bronze plans with significantly higher costs.

The share of consumers choosing bronze plans rose from 30% in 2025 to 40% in 2026, while silver plan enrollment fell to a record low of 43%.

As a result, average deductibles in the ACA Marketplace rose 37%, from $2,759 in 2025 to a record $3,786 in 2026 – the steepest increase since the ACA Marketplaces were created.

Low-income consumers who qualify for cost-sharing reductions have also increasingly moved away from silver plans, even though those plans offer much lower deductibles.

Young adults are dropping coverage at high rates

Young adults ages 18 to 34 accounted for the largest share of enrollment losses.

Market registrations in this age group fell by about 542,000 people, or 8%, accounting for nearly half of the overall decline in enrollment.

Insurers have previously warned that younger and healthier consumers will be among the first to leave the Marketplace if the subsidy ends because they are more sensitive to premium increases.

Differences emerge at the state level

Marketplace enrollments fell in 41 states, with North Carolina, Ohio and West Virginia seeing some of the steepest declines.

However, several states have managed to stabilize or even increase enrollment through additional state-funded subsidy programs. New Mexico saw an 18% increase in Marketplace registrations after implementing supplemental financial aid programs to offset the loss of federal subsidies.

Analysts warned that the full impact of the subsidy expiration may not be felt until later in 2026, as more consumers lose coverage due to non-payment or rising health care costs.