Millions Lose Marketplace Coverage and Pay More After Boosted ACA Subsidies Lapse

Six months after enhanced Affordable Care Act marketplace subsidies expired, early enrollment and payment data suggest the individual insurance market has lost millions of active enrollees and left many who kept coverage paying sharply more.

A new report published Tuesday by Human Rights Watch and co-signed by Oxfam America argues that the Jan. 1 expiration of the enhanced subsidies caused major coverage losses and higher costs. Independent estimates cited by KFF, the health policy research group, point in the same direction. KFF reported that marketplace plan selections fell from about 24.3 million for 2025 coverage to about 23.1 million for 2026, a drop of roughly 1.2 million. The steeper decline appears to be in effectuated enrollment — meaning people who selected a plan and paid the premium, so they actually had coverage. KFF, citing Wakely Consulting Group estimates, said average monthly marketplace enrollment in 2026 could fall to about 17.5 million and could be as low as 16.5 million, down from about 22.3 million in 2025. Official nationwide uninsured figures for 2026 are not yet available, and those larger declines are estimates rather than final federal counts.

The cost hit for people who stayed in the market has also been substantial. KFF reported that average monthly premium payments after tax credits rose about 58% this year, to about $178 from about $113 in 2025. Average deductibles rose to $3,786 in 2026 from $2,759 in 2025. Consumers also appear to be shifting into less generous coverage to keep premiums down: silver-plan enrollment fell from 57% to 43%, while bronze-plan enrollment rose from 30% to 40%.

Early survey data point in the same direction. In a KFF survey of adults who had marketplace coverage in late 2025, about 9% said they had become uninsured in early 2026. Among those who lost coverage, 80% cited increased cost as the reason.

The Affordable Care Act created insurance marketplaces and premium tax credits for people who buy coverage on their own. Congress temporarily made those subsidies more generous in 2021 and removed the hard income cutoff above 400% of the federal poverty level. The Inflation Reduction Act later extended those enhanced credits through 2025. After Congress did not renew them for the 2026 plan year, the pre-2021 rules returned this year, including the old “subsidy cliff” that cuts off assistance entirely above 400% of poverty.

That change hit some groups especially hard. KFF reported that the steepest premium increases fell on older consumers and people with incomes above 400% of the federal poverty level, who once again faced that cutoff. KFF also said about 14% of people who enrolled in 2026 marketplace coverage did not pay their first monthly premium, another sign that sticker shock kept some consumers from activating the plans they chose.

Enrollment declines were widespread but not universal. KFF found marketplace sign-ups fell in 41 states. Among the largest percentage drops were North Carolina, down about 22%, and Ohio, down about 20%. New Mexico stood out as a counterexample. The state used its own funds to largely offset the loss of the federal subsidy boost for 2026, and KFF and state exchange data showed plan selections there rose by roughly 18%.

The Human Rights Watch and Oxfam America report frames those changes as the direct result of a policy decision to let the temporary aid lapse. “Congress’ choice to let these subsidies end has led millions to become uninsured and is forcing many to pay far more for care that they have a right to,” said Matt McConnell, an economic justice and rights researcher at Human Rights Watch.

The clearest picture so far is not in the final uninsured count, which federal data has not yet provided, but in the marketplace itself: fewer people are selecting plans, far fewer may be following through and paying for them, and those who remain are often buying skimpier coverage at higher cost.