Nearly 5 million fewer people are expected to sign up for Affordable Care Act marketplace coverage this year, according to an analysis released by the health care research nonprofit KFF. The group projects that enrollment could decline by nearly 5 million—dropping more than 20%—as subsidies expire and costs rise for people who remain in coverage. KFF said the enrollment shift reflects how higher health costs are forcing some Americans to make mid-year choices about whether to keep their plans.
KFF’s analysis projects that ACA enrollment could fall from 22.3 million Americans in 2025 to around 17.5 million in 2026. The report said that would represent a significant reduction in participation in the government’s subsidized health insurance program for working-age people who do not qualify for Medicaid. KFF said it used federal and state data and relied on findings from the actuarial firm Wakely Consulting Group.
Cynthia Cox, a vice president at KFF and co-author of the report, said cost pressures are not limited to monthly premiums. “No matter how you slice it, people are paying more,” Cox said, describing increased burdens for enrollees even when people remain covered. KFF reported that the average enrollee’s deductible is growing by more than $1,000, and that average monthly premium payments rise by $65.
KFF said the projected enrollment drop is much larger than initial federal data suggested, and it linked the change in part to the Jan. 1 expiration of subsidies that had helped most enrollees pay for coverage. The report also described how people who were auto-renewed from last year could end up facing much higher prices once those subsidies end. Cox said that when people become unable to pay the monthly fees partway through the year, they lose coverage.
The analysis found that a higher proportion of middle-income Americans dropped coverage compared with other groups. KFF said those enrollees make too much to qualify for remaining subsidies reserved for lower-income people, but not enough to comfortably afford coverage without the enhanced, COVID-era subsidies that are now expired. KFF also found that drops in ACA sign-ups occurred across most states.
KFF said state outcomes varied depending on how exchanges were run. The report said states that had their own exchanges retained a larger percentage of enrollees than states that relied on the federal marketplace. KFF’s analysis did not suggest the changes were uniform everywhere, but it projected enrollment declines broadly across the country.
In the 2026 coverage landscape, KFF reported that those who keep plans also face higher average costs. It said premium payments jumped by 58% on average after KFF previously expected premium payments would more than double when the enhanced subsidies expired. KFF said some people downgraded to lower-premium, higher-deductible plans—an approach that can reduce monthly costs, but can raise what people pay if they need to use care.
Cox also described insurers’ expectations about how people would adjust to the market changes. She said she is hopeful the marketplace shift could be temporary. “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,” Cox said.
Among the individuals affected is Caitlin McElroy, 38, in Orlando, Florida, who KFF described as facing a sharp premium increase while managing chronic health needs. McElroy said her premium payment rose from $32 to $89 per month, and she said she needs the coverage to manage her Crohn’s disease and her mental health. She told KFF she makes it work by cutting other spending, including delaying utility payments and reducing fresh produce in her diet when she can’t afford it. “I try to just cut corners wherever I can,” McElroy said.
The projected enrollment declines and cost pressures are likely to land as political issues as voters focus on economic stress in the midterm elections, the analysis said. The Centers for Medicare and Medicaid Services, whose final 2026 enrollment data is not yet public, did not immediately respond to a request for comment on KFF’s report, according to KFF.