Texas Children’s Hospital’s Kangaroo Crew members walk through the hallways during a simulation at the hospital in Houston on Sept. 23, 2025.
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About 22.8 million Americans have so far signed up for 2026 health insurance via the Affordable Care Act marketplace, according to data issued Monday by the Centers for Medicare & Medicaid Services. That’s a decline of about 1.5 million from the 24.3 million people who had enrolled in health care coverage for 2025.
The data amount to an early sign of the fallout from the recent lapse of enhanced premium subsidies that the federal government had offered since 2021.
Now, health experts expect millions of people to drop their coverage amid soaring health premiums — an issue that may threaten Republican success in this year’s congressional midterms, since most ACA enrollment growth in recent years has occurred in red states, data shows.
Without the enhanced subsidies, which expired at the end of 2025, the average recipient will see their premiums more than double this year, according to KFF, a health policy research group.
Health experts credited the enhanced ACA subsidies, which made insurance more affordable for consumers, with greatly reducing the number of uninsured Americans since taking effect. Total ACA enrollment had hovered around 11 million to 12 million from 2015 to 2021, but doubled to more than 24 million by 2025, once the enhanced subsidies were in force.
Now, coverage is poised to become a greater focus as millions of Americans are expected to drop insurance altogether amid high costs.
“The health policy debate in recent years really has been predominantly about costs, as the coverage challenge had largely been resolved,” said Jonathan Burks, executive vice president for economic and health policy at the Bipartisan Policy Center. “Expiration of the enhanced subsidies has reopened that coverage debate.”
Nearly 5 million may drop ACA coverage
The CMS data doesn’t yet paint a complete picture of enrollment for 2026. Health experts expect more households to drop their coverage in the coming months.
For one, the figures don’t yet encompass the whole open-enrollment period, which runs through Jan. 15. The most recent CMS enrollment data was current as of Jan. 3 for states using the federal Healthcare.gov platform and Dec. 27 for state-based ACA exchanges. People still have time to decide if they will sign up or not.
Additionally, the figures include people who were enrolled in a health plan in 2025 and were automatically re-enrolled into the same plan for 2026.
Once they start paying their initial premiums in the coming weeks, they may opt to drop their coverage if they deem it too expensive, experts said.
“It’s too soon to say how big of a drop this will end up being,” Jared Ortaliza, a policy analyst at KFF who focuses on the Affordable Care Act, wrote in an e-mail. “Compared to around the same time last year, new data released by CMS shows fewer people are signed up for ACA Marketplace plans. If this remains true by the time Open Enrollment ends, it would be the first time since 2020 when year-to-year signups have declined.”
The true impact of the lapse in enhanced premium subsidies “may be obscured” until mid-year, said Jessica Banthin, a senior fellow in the health policy division at the Urban Institute and the former deputy director for health at the Congressional Budget Office.
That’s generally when CMS issues a report on “effectuated enrollment,” Banthin said. Health insurance selections aren’t activated, or “effectuated,” until enrollees pay a premium, she said.
Urban Institute economists estimate 4.8 million total people will drop their health coverage and be uninsured in 2026 due to lapsing subsidies.
“The risk of having an unmanageable health bill is real, given the overall increases in prices in the health sector,” Burks said, highlighting the financial risk of forgoing insurance coverage.
Another 2.5 million people will drop their ACA coverage but find alternative insurance, perhaps via employer-sponsored coverage or via Medicaid, depending on their circumstances, said Banthin, who co-authored the Urban analysis.
Others are expected to stay in the ACA market but enroll in high-deductible plans that carry cheaper premiums but higher upfront costs for care, experts said.
“A good health care system means our labor force is healthy and productive,” Banthin said. “If large segments of our working-age population can’t get access to health care, that’s ultimately detrimental to the economy.”
Health coverage may be a key political issue
J. David Ake | Getty Images News | Getty Images
The expired subsidies are also shaping up to be a key political issue as congressional midterm elections loom at year’s end and at a time when affordability is top of mind for households.
Overall ACA enrollment has more than doubled since 2020, from roughly 11 million to a record-high 24 million in 2025, according to a KFF analysis of federal data.
Most of that enrollment boost came in states that President Donald Trump won in the 2024 election.
About 88% of the total growth in the ACA marketplace since 2020 — 11.4 million out of 12.9 million new enrollees — is from such states, according to KFF.
On average, enrollment increased by 157% in the states that voted for Trump, while states that voted for former Vice President Kamala Harris saw a 36% increase, KFF found. Enrollment more than tripled in Texas, Mississippi, West Virginia, Louisiana, Georgia and Tennessee, it said.
The subsidies were at the epicenter of the fight to end a record-long government shutdown that ran from Oct. 1 to Nov. 12.
Democrats in Congress have pushed to extend the enhanced subsidies, while the vast majority of Republicans have said they’re opposed to doing so.
A group of 17 House Republicans voted with Democrats on Thursday to extend the subsidies. The measure faces long odds in the GOP-controlled Senate, which voted down a three-year extension in December.
Trump has also threatened to veto such a measure.
