As some subsidies for health insurance plans purchased on U.S. states’ marketplaces under the Affordable Care Act expire, KFF is predicting an unprecedented drop in enrollment for ACA health care plans this year. While in 2025, more than 22 million Americans were insured through ACA marketplaces, this is expected to fall to just 17.5 million this year.

During open enrollment at the beginning of 2026, sign-ups and renewals only fell by about a million, the organization said. However, as many enrollees fail to pay their now much higher premiums, experts estimate the real number of insured people will drop five million below last year’s level.

During the Biden administration, the federal government widened subsidies for ACA coverage. So-called enhanced premium tax credits meant that Americans with incomes above 400% of the federal poverty line could receive tax credits on their health plans for any cost exceeding 8.5% of their income. As of 2026, anyone earning more than 400% of the federal poverty line limit will once again pay the full price of their insurance — often thousands of additional dollars per year — and therefore fall off the often-cited subsidy cliff.

For people earning more than their state’s limit for Medicare coverage (100-138% of the FPL) but less than 400% of the FPL, income caps spelled out in premium tax credit rules are also rising slightly. On top of this, insurance plans have been subject to high inflation between this year and last year, making health insurance severely unaffordable for ACA marketplace users of different income levels. KFF last year calculated that for a 45-year-old single, additional annual cost could be in the range of $400 (for small incomes) to $2,400 (for those incomes right beyond the subsidy cliff). For a 60-year-old couple, price increases could be closer to $19,000 to $22,000 for those losing enhanced credits.

Additional data published by KFF shows that the number of ACA marketplace enrollees with incomes around 400-500% of the federal poverty level decreased by 44% in the 2026 enrollment period compared to one year earlier. The number of those enrolling with incomes above 500% of the FPL was down by 27%.

Enrollment decreased by more than 20% in South Carolina and in between 15-20% in Ohio, Indiana, West Virginia, Oklahoma, Oregon and Arizona. As states can also set their own subsidies for their marketplaces, enrollment was also up in some locations, for example in Texas (by 5%) and in Massachusetts and Connecticut (by 4% each). The biggest rise could be seen in New Mexico (+18%) as the state legislature has designated $40 million for the first half of 2026 to fill the gap of the expired federal subsidies.

Due to the higher prices of the insurance plans themselves, many who would still receive premium tax credits also dropped coverage. While the relative decrease was smaller for these groups, they constitute a larger share of ACA marketplace users, meaning losses in the absolute number of people losing insurance were still substantial. Further data by Mercer estimates that employer-sponsored plans will also go up in price by almost 7% this year, constituting an extra burden for employees and employers. The report specifically mentioned increased use of pricey GLP-1 weight loss drugs as a reason cost is up.