More than 5 million Americans are expected to leave the Affordable Care Act insurance marketplaces this year after federal subsidy enhancements expired, triggering steep premium increases and intensifying pressure on households already struggling with healthcare costs.
New projections from KFF estimate that enrollment in ACA marketplace plans could fall by more than one-fifth in 2026, dropping to 17.5 million people from 22.3 million the previous year. The decline follows the expiration of enhanced premium tax credits first introduced during the Biden administration in 2021 to lower monthly insurance costs for millions of Americans.
The sharp reversal has reopened political and economic debate in Washington over healthcare affordability as lawmakers failed to reach an agreement to extend the subsidies before they expired at the end of 2025.
"Costs went up significantly and a lot of people dropped their plans," KFF researcher Cynthia Cox said.
The ACA marketplaces, created under the Affordable Care Act signed by former President Barack Obama, have become a critical source of coverage for millions of Americans who do not receive employer-sponsored insurance. The system is widely used by:
- Self-employed workers
- Gig economy contractors
- Early retirees
- Small business owners
- Households without workplace health benefits
Without the enhanced subsidies, many consumers faced immediate increases in monthly premiums and deductibles at the start of 2026.
KFF had initially projected average premiums could rise by as much as 114% following the subsidy expiration. The actual increase, while lower than feared, still proved severe. Average monthly premiums climbed 58%, rising to $178 from $113 per month.
The financial strain also pushed many consumers toward lower-tier insurance products with significantly higher out-of-pocket exposure.
According to KFF data:
- Enrollment in bronze-tier plans rose to 9.2 million in 2026 from 7.3 million a year earlier
- Average deductibles across ACA plans increased 37%
- Deductibles climbed to $3,786 from $2,759 in 2025
KFF described the deductible increase as "the steepest increase in history."
The shift toward cheaper plans reflects a broader reality confronting many households: keeping monthly premiums manageable often now means accepting far higher medical costs when care is actually needed.
"Those who stayed [in the marketplaces] are paying more, either in the form of higher premiums or higher deductibles or both," Cox said. "What ended up happening is that a lot of people who had the steepest increases dropped coverage. Also, a lot of people moved on to a lower level of coverage that has a much higher deductible."
Researchers believe many of the estimated 5 million people leaving ACA marketplaces are likely becoming uninsured rather than transitioning to alternative coverage options.
That prospect has alarmed healthcare analysts, who warn that uninsured households frequently delay doctor visits, avoid preventive care and face greater financial exposure during medical emergencies.
Cox also noted the broader economic consequences tied to rising insurance costs.
"Staying uninsured attracts higher costs during doctor visits," she said, adding that higher premiums can leave households without enough money to actually seek medical care even while insured.
Despite the enrollment decline, some analysts see signs that insurers may have successfully anticipated the market disruption. Cox suggested the current surge could represent a temporary "one-year shock" rather than the beginning of repeated annual instability.
"It might mean that we don't see a lot of insurers needing to do another big market correction," she said.
