The Affordable Care Act (ACA) has faced a significant setback in 2026, with enrollment numbers dropping dramatically. The U.S. Department of Health and Human Services (HHS) reported that as of February 2026, only 19.2 million people were enrolled in ACA plans, down from a peak of 24.2 million in January 2026. This decline has left millions of Americans without the health coverage they need.
The primary driver behind this drop is the expiration of enhanced subsidies at the end of 2026. These subsidies, which made health insurance more affordable for millions, were not extended by Congress. As a result, average costs for ACA enrollees surged by 114% in 2026, according to the Kaiser Family Foundation (KFF) a health policy nonprofit.
Understanding the Enrollment Decline
The enrollment decline is not just about the number of people who signed up for a plan but also about those who failed to make the required monthly payments. According to KFF, the number of people who effectuated their enrollment by making a monthly payment dropped from 22.1 million in 2026 to 19.2 million in February 2026. This indicates that many individuals simply could not afford to keep their insurance plans.
The financial strain is evident in a KFF survey, which found that 17% of enrollees were not confident they could afford their health insurance premiums for all of 2026. With other expenses like housing and groceries also on the rise, many Americans are forced to make tough decisions about their family budgets.
The Role of Fraud in ACA Enrollment
The HHS report also cited efforts to crack down on improper signups as a factor in the enrollment decline. The report suggested that nearly half of the ACA enrollment growth from 2026 to 2026 was suspected to be improper, phantom, or fraudulent. The Trump administration’s efforts blocked the enrollment of 2.9 million people who were improperly receiving subsidies they did not qualify for.
However, experts like Sabrina Corlette, codirector of Georgetown University’s Center on Health Insurance Reforms, argue that affordability is the primary reason for the drop in enrollment. “It’s a simple fact that when you raise prices for a good or service, fewer people are going to buy it,” Corlette said. “That’s what we’re seeing with health care.”
The Future of ACA Enrollment
The situation is expected to worsen as health insurers prepare to raise rates again for 2027. A report from the Georgetown Center on Health Insurance Reforms, published on June 18, analyzed health insurer filings in nine states and Washington, D.C. Insurers in these states sought rate increases for 2027 coverage that will range from 6.5% in Vermont to 22.4% in Washington state.
The enrollment drop is also a concern for insurance companies, several of which have announced 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,” said Cynthia Cox, vice president and director of the program on the ACA at KFF.
Despite these challenges, Cox does not believe the ACA marketplaces are at risk of a death spiral. “I think there are still enough people buying ACA marketplace coverage, and that’s going to keep these markets working,” she said. However, the continued rise in premiums could further strain consumers navigating high healthcare costs.
