The Republican-led termination of enhanced subsidies for Affordable Care Act plans is beginning to rattle state marketplaces, with early data showing more than a million Americans have already dropped coverage. Experts and state officials warn the exodus will accelerate as provisions from the One Big Beautiful Bill Act and potential Trump administration regulatory changes take hold.
According to preliminary Centers for Medicare and Medicaid Services data, total ACA enrollment for 2026 fell to roughly 23 million, a decline of just over 1 million from the previous year. Insurers and analysts project the drop could reach 25 percent by year's end. HealthCare.gov enrollment slid nearly 8 percent compared to final 2025 numbers, while state-based exchanges saw a modest 2 percent increase, per an Oliver Wyman analysis. New consumer enrollment plummeted 14 percent, far outpacing the 3 percent decline among returning enrollees.
Choice is shrinking too. Cigna Group announced it will exit the marketplace next year, joining CVS Health's Aetna, which stopped offering plans this year. “I think it's safe to say that when insurers who care about their stock value and their profits begin to leave a market, there's something wrong with that market,” said Jeanne Lambrew, a former Obama health adviser and top Maine health official.
California's marketplace, Covered California, reported 374,000 cancellations this year, up from 240,000 last year. “There's no other explanation for such a delta between what is normal and what we've experienced… there's no question people are being priced out of the marketplace right now,” said executive director Jessica Altman. In Idaho, Your Health Idaho saw 25,000 disenrollments after open enrollment, with 5,000 during it. Executive director Pat Kelly noted affordability concerns dominated buying decisions but believes the worst is past.
The Trump administration and conservative think tank Paragon Health have downplayed the losses, attributing them largely to a reduction in fraudulent enrollments. They note most consumers remain eligible for some subsidies, even without the enhanced premium tax credits.
Democrats shut down the government for a record 45 days last year in a failed bid to extend the subsidies, ultimately securing only a symbolic vote that fell short. The extra credits expired at the start of this year, prompting insurers to raise premiums in anticipation of healthier members dropping out.
Experts don't foresee a full “death spiral” like 2017's insurance deserts, but the trend is troubling. “Will the marketplace be as affordable and as accessible with as many choices? No. Will it collapse? I think the answer is probably no,” Lambrew said. Yet falling enrollment and a shift toward high-deductible bronze plans—60 percent of Maine's ACA enrollees now choose them—are raising stability concerns.
“The dust has yet to settle in terms of what the expiration of the enhanced [premium tax credits] will mean for the marketplace. But it's incontrovertible that it has resulted, and is likely to result in a smaller and sicker market,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “Insurance companies like stability… this is definitely a market that's going to be in flux.”
Despite the turmoil, insurers posted strong first-quarter results, managing pressures by scaling back benefits, raising prices, or exiting altogether. The political fallout is expected to feature prominently in November's midterms, as health costs hit voters hard. Meanwhile, the broader healthcare landscape faces additional strain, with some states exploring modernized rural health laws to expand telemedicine and nurse practitioner roles, and others gearing up for health emergency readiness ahead of the World Cup.
