The Affordable Care Act (ACA) health insurance marketplace could see a nationwide enrollment drop of nearly 5 million people this year, according to a new analysis from KFF, a healthcare research nonprofit. The report, released May 19, 2026, also found that those who remain covered are facing higher healthcare costs, with deductibles growing by more than $1,000 and average monthly premium payments rising by $65.

Cynthia Cox, a KFF vice president and co-author of the report, said that “no matter how you slice it, people are paying more.” The projected drop-off is more significant than initial federal data suggested, revealing that rising health costs and the January 1 expiration of subsidies are forcing Americans to make difficult decisions about maintaining their health coverage.

The expiration of COVID-era subsidies, which offset costs for ACA users for the past four years, is a key factor. KFF had previously projected that premium payments would more than double in 2026, but the new analysis found a more modest jump of 58% on average. This was partially because many people downgraded to lower-premium, higher-deductible plans.

Cox noted that “people are trying to hang on to their health insurance coverage any way they can, even if that means they have a deductible of $7,000.”

Caitlin McElroy, 38, of Orlando, Florida, said her premium payment soared from $32 to $89 per month. She needs the coverage to manage her Crohn’s disease and her mental health. McElroy said she manages the higher costs by sacrificing social events, delaying utility payments, and cutting fresh produce out of her diet when she can’t afford it. “I try to just cut corners wherever I can,” she said.

KFF found that drops in ACA sign-ups occurred across most states, with states that operate their own exchanges retaining a larger percentage of enrollees than those relying on the federal marketplace. The Trump administration has maintained that federal efforts to root out fraud in the ACA program are responsible for most of this year’s drop-offs.

Cox said that insurers seem to have predicted and already made adjustments for many of the marketplace changes, which could mean future health costs may not rise as sharply. “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.