Federal data show about 5 million people in 29 Healthcare.gov states disenrolled or failed to pay ACA marketplace premiums for 2026 after enhanced tax credits expired and premium costs jumped. Advocates and policy experts argue the coverage loss tracks afforda
For millions of Americans, the decision wasn’t about health care philosophy. It was about math.
On Friday, the U.S. Department of Health and Human Services released new data showing that about 5 million people who had signed up for Affordable Care Act coverage for 2026 in the 29 states that use Healthcare.gov either disenrolled or failed to pay their premiums and therefore dropped coverage. The enrollment loss comes after a premium shock hit the marketplaces following the expiration of enhanced financial help for enrollees last year.
Officials and analysts had warned that the picture would worsen. After initial sign-ups for 2026 showed that 1 million fewer people picked a plan compared with the year before, experts expected more people would fall out once they confronted higher premium bills.
Cynthia Cox. director of KFF’s Program on the ACA. put the scale in plain terms: “The main takeaway is that enrollment is down 13% from last year.” She said the Trump administration has attributed the decline to efforts to address fraud. But Cox said the coverage loss happened as millions of people faced premium increases in the double digits and sometimes higher—after enhanced tax credits expired.
The administration’s fraud theory has been pushed by the Paragon Health Institute. a conservative think tank influential in the Trump administration. Many health policy experts are skeptical. They argue enrollment grew during the pandemic years for a reason that had nothing to do with deception: Congress invested billions of federal dollars in enhanced premium tax credits that made insurance far more affordable.
Cox said the marketplaces doubled in size during the period when those enhanced subsidies were available because coverage was “much more affordable and much more appealing to people.” She and others said the drop this year fits a predictable pattern. too—premium costs doubled on average from 2025 to 2026.
Those price increases didn’t appear out of nowhere. The costs went up after Republican lawmakers let the enhanced premium tax credits expire. Democrats, in turn, shut down the government in October 2025 while trying to negotiate an extension that would have kept prices lower.
“When their costs went up, many of them dropped their coverage,” Cox said.
She also said fraud, while real in the ACA marketplaces, doesn’t add up to an explanation for a loss as large as 5 million fewer enrollees. Stacey Pogue, a senior research fellow at the Georgetown Center on Health Insurance Reforms, echoed that skepticism.
“I don’t see data that point to that conclusion that a 5 million person drop can be explained by allegations of fraud,” Pogue said. “There’s lots of evidence pointing to people making decisions based on what they can pay each month.”
The pressure isn’t confined to insurance forms or enrollment portals. With the economy still struggling with inflation. people have been forced to make hard tradeoffs inside family budgets—deciding what to pay for. where to work. and even which life plans to prioritize—after Congress let prices rise.
The shakeout is also reverberating through the insurance industry. Several insurers have already said they will not be participating in ACA markets next year, including Cigna.
“If there are fewer customers, then that makes the market less appealing to insurance companies,” Cox said. The problem is sharper because the people who drop coverage tend to be healthier, leaving a marketplace with a sicker risk pool and higher costs.
That churn carries a familiar warning about insurance markets: the danger of a “death spiral.” If healthier enrollees keep exiting, premiums can rise further, and the cycle can worsen.
At this point, Cox said she isn’t convinced the system is sliding toward that outcome. “I think there are still enough people buying ACA marketplace coverage and that’s going to keep these markets working. ” she said. “At this point. we don’t see any parts of the country that are at risk of having no insurance company.” She said if insurers did abandon the markets in more places. that would be what a death spiral might look like.
Even without a collapse, the financial strain is expected to persist. Premiums for marketplace plans are on track to keep rising, which could continue to pummel consumers trying to manage high health care costs. Enrollment may also continue to shrink.
Pogue’s recent analysis at Georgetown, based on early insurance rate filings for 2027, suggests rates are set to go up again next year.
ACA Affordable Care Act Healthcare.gov 2026 enrollment drop HHS data enhanced premium tax credits Paragon Health Institute KFF Cynthia Cox Georgetown Stacey Pogue insurer exits Cigna death spiral