A new analysis from KFF estimates that between 4.8 million and 5.8 million people could lose their Affordable Care Act marketplace coverage this year, following the expiration of enhanced premium tax credits in 2025. The report, released Tuesday, highlights a sharp reversal after four consecutive years of record enrollment growth driven by the subsidies, which had made many plans available with zero-dollar premiums.
By the end of 2025, congressional talks to extend the credits collapsed, and lawmakers have largely moved on from the issue. The result: enrollment in ACA plans fell for the first time in four years during the 2026 open enrollment period, with about 1.2 million fewer people signing up. KFF expects that number to climb as households struggle with higher monthly costs.
Subsidy Cliff Hits Middle-Income Enrollees Hardest
The analysis found that consumers just above the so-called “subsidy cliff”—those with incomes too high to qualify for premium assistance—made up only 7% of 2025 enrollment but accounted for nearly half (48%) of the decline in plan selections from 2025 to 2026. KFF noted that household income data is missing for about 1 million enrollees, so the actual share above the cliff could be even higher.
Average monthly premium payments have jumped 58%, rising by $65 on average, according to the analysis. Enrollment drops were especially steep in North Carolina, Ohio, and Indiana, among the 41 states that saw fewer plan selections.
Young Adults Hit Particularly Hard
Adults aged 18 to 34 experienced the largest enrollment decline of any age group. Analysts had predicted younger people would be most affected by the credit expiration, as they are less likely to have stable employer-based coverage and more sensitive to price increases.
The Centers for Medicare and Medicaid Services (CMS) attributed part of the enrollment drop to its own crackdown on fraud. In a March press release, CMS stated that it had “ended advance payment of the premium tax credit or coverage for nearly 1.5 million people found to be either ineligible for financial assistance, or enrolled without their authorization on the HealthCare.gov platform.”
Critics argue that while fraud enforcement is necessary, the administration’s actions may have exacerbated coverage losses for legitimate enrollees. The KFF analysis suggests that the subsidy cliff remains the primary driver of the decline, not fraud detection.
The broader political context remains fraught. Congress has shown little appetite for reviving the enhanced credits, which were originally enacted as part of the American Rescue Plan in 2021 and extended through the Inflation Reduction Act. With the 2026 midterm elections approaching, the coverage losses could become a flashpoint, especially in states like Arizona—which leads the nation in FTC spam call complaints—where healthcare affordability is a top concern.
Meanwhile, the Trump administration has pursued regulatory changes that could reshape the insurance landscape further. A recent rule allows firms to offer fertility coverage without adhering to ACA mandates, a move that could segment the market and increase costs for those with pre-existing conditions.
For now, the KFF analysis underscores the fragility of the ACA marketplace without robust subsidies. As open enrollment for 2027 approaches, advocates warn that millions more could lose coverage unless policymakers act.
