Health Watch: ACA premiums and deductibles rise as enrollment falls

Affordable Care Act enrollment has fallen by nearly 3 million people this year as consumers confront sharply higher premiums, rising deductibles and the expiration of federal subsidies that helped drive marketplace enrollment to record levels.

About 19.2 million people had active marketplace coverage in February 2026, down from 22.1 million a year earlier, according to federal data analyzed by KFF. That represents a decline of roughly 13 percent.

The drop is the sharpest reversal for the ACA marketplaces in years. Marketplace enrollment rose from 11.4 million in 2020 to 21.4 million in 2024 and reached a record 24.2 million plan selections during the 2025 open-enrollment period, according to the Centers for Medicare & Medicaid Services.

The decline comes as consumers are paying substantially more for the coverage they retained.

CBS News reported that the average marketplace customer is paying $178 a month in 2026 after available subsidies, a 58 percent increase from 2025. Average deductibles rose 37 percent to nearly $3,800.

Those averages can conceal much larger increases for older people, families and households that lost eligibility for assistance.

The full, unsubsidized cost of an average marketplace policy is much higher than the amount most customers pay directly. KFF estimated that the average annual premium before tax credits increased to about $1,904 per enrollee in 2026, compared with $888 in 2025. The federal tax credit covers part of that cost for eligible households, but consumers are responsible for the remainder.

For some middle-income households, the increase was especially severe because they once again became subject to the ACA’s so-called subsidy cliff.

KFF estimated, for example, that a 60-year-old couple earning $85,000 could face an increase of more than $18,000 a year because their income placed them just above the restored eligibility cutoff. Depending on age, location and family size, some households faced increases of $20,000 or more.

The subsidies that fueled record enrollment

The enhanced premium tax credits were introduced through the American Rescue Plan Act in 2021 and extended through the end of 2025 by the Inflation Reduction Act.

The changes increased assistance for people who were already eligible for ACA subsidies and extended help to households earning more than 400 percent of the federal poverty level. They also capped the cost of a benchmark marketplace plan at no more than 8.5 percent of household income.

Before that change, households earning even slightly more than four times the poverty level could lose their entire subsidy.

The additional assistance helped produce a rapid expansion of marketplace coverage. Enrollment increased from 12 million in 2021 to 14.5 million in 2022, 16.4 million in 2023 and 21.4 million in 2024. More than 24 million people selected plans for 2025, Centers for Medicare & Medicaid Services said.

Congress allowed the enhanced credits to expire on December 31, 2025. The original, less generous ACA subsidy formula returned in January 2026.

KFF had estimated that premium payments would more than double on average if the enhanced credits expired. The Congressional Budget Office projected that failing to extend them would eventually increase the uninsured population by roughly 3.8 million people compared with an extension.

The enrollment figures released so far suggest the initial effect has been substantial, although the final annual total may fall further as people stop paying premiums or lose coverage during the year. KFF has estimated average effectuated enrollment could decline to about 17.5 million in 2026 and potentially as low as 16.5 million.

Administration cites improper enrollment

The Trump administration offers a different explanation for much of the decline.

A Department of Health and Human Services report estimated that 5.6 million people were improperly or fraudulently enrolled in marketplace plans in February 2025. The agency said it had removed about 2.9 million enrollments and estimated that another 2.6 million improper or “phantom” enrollments remained.

Administration officials have described the decrease as evidence that tighter income verification and enrollment controls are removing people who were never eligible, had been enrolled without their knowledge or were maintaining zero-premium plans they did not use.

There is evidence that unauthorized enrollments and plan switches have been a genuine marketplace problem. CMS said complaints and cancellations linked to unauthorized activity rose sharply in 2023 and 2024, although the agency reported that cancellations declined in 2025 after it strengthened system safeguards and took enforcement action against brokers and enrollment companies.

But the administration’s broader estimate is disputed.

Some of the fraud calculations have relied on discrepancies between income reported on marketplace applications and income shown in other federal data. Health-policy analysts have cautioned that such discrepancies do not necessarily prove fraud: income can fluctuate, federal records can lag and marketplace eligibility is based partly on a household’s estimate of its income for the coming year.

The 5.6 million figure also combines several categories—including potentially improper, unverifiable and phantom enrollments—that do not all represent proven intentional fraud.

That distinction matters because the administration is presenting the removal of improper coverage as a central explanation for the enrollment decline, while KFF and other analysts point to a strong concentration of enrollment losses among people facing the largest premium increases.

KFF found that 27 percent of the decline occurred among people earning between 400 and 500 percent of the federal poverty level, even though that group represented only 3 percent of marketplace plan selections in 2025. Those households were among the first to lose eligibility for enhanced assistance.

The two explanations are not necessarily mutually exclusive. Some enrollment may have disappeared because of improved verification, while other consumers dropped coverage because they could no longer afford it.

For a family deciding whether to keep a policy, however, the immediate issue is usually not the Washington debate over enrollment integrity. It is the amount due each month.

Hospitals are beginning to feel the effect

Hospitals are seeing the consequences from the other side of the transaction.

Major hospital systems have reported increases in uninsured patients, unpaid medical bills and people postponing elective or preventive care.

HCA Healthcare executives said former ACA patients appeared to be moving “almost one for one” into the uninsured population. The company reported approximately $400 million in uninsured-care costs during one quarter and has warned that the loss of marketplace coverage could reduce annual operating profit by about $1 billion. Community Health Systems reported roughly a 20 percent increase in visits by uninsured patients, according to The Wall Street Journal.

The effect extends beyond large hospital chains. Rural hospitals, community health centers and safety-net hospitals generally operate with narrower margins and are more vulnerable when insured patients become uninsured.

Hospitals are required to evaluate and stabilize patients with emergency medical conditions regardless of their ability to pay. When a patient has no insurance and cannot pay the bill, much of that cost becomes uncompensated care.

Those losses can eventually lead hospitals to raise prices elsewhere, reduce services, postpone investments or close departments. Maternity care, behavioral-health services and rural facilities are often among the most vulnerable.

Coverage losses can also change when patients seek treatment.

People without insurance are more likely to delay routine appointments, diagnostic testing and prescription refills because of cost. They may eventually arrive at an emergency department with a condition that is more advanced, more difficult and more expensive to treat.

A premium is only part of the cost

Consumers who kept their marketplace coverage may still struggle to use it.

The average deductible of nearly $3,800 means that many enrollees must pay thousands of dollars out of pocket before their policy begins covering most nonpreventive services. A family plan may have a substantially higher combined deductible.

Preventive services covered by the ACA—including many vaccines, screenings and annual wellness visits—generally remain available without a deductible when obtained from an in-network provider. But diagnostic tests, specialist visits, emergency care, imaging and hospital treatment can generate significant bills.

Consumers choosing a lower-premium bronze plan may face particularly high deductibles and other cost sharing. Silver plans can provide better protection for lower-income consumers who qualify for separate cost-sharing reductions, but those reductions are available only when the consumer selects a silver plan.

A policy with a manageable premium can therefore still leave a household exposed to several thousand dollars in medical expenses.

What consumers can do

Consumers who are having trouble paying for marketplace coverage should not simply allow the policy to lapse without reviewing their options.

Income changes can alter the amount of premium assistance available. Someone who lost work, had hours reduced, retired or experienced another household change may qualify for a larger tax credit than the marketplace originally calculated.

Consumers should update their projected annual income through HealthCare.gov or their state marketplace rather than waiting until the next open-enrollment period. They should also compare all available plans, because the least expensive option from the previous year may no longer be the best value.

Households should look beyond the monthly premium and compare:

• The annual deductible.
• Copayments and coinsurance.
• The maximum out-of-pocket limit.
• Prescription-drug coverage.
• Whether doctors and hospitals are in the plan’s network.
• Whether the plan qualifies for cost-sharing reductions.

People who lose marketplace coverage may qualify for a special enrollment period, Medicaid, the Children’s Health Insurance Program or an employer plan through a spouse or family member.

Consumers who believe they were enrolled in a plan or switched to another policy without permission should contact the marketplace immediately. Unauthorized enrollment can affect tax credits and may produce problems when the household files its federal tax return.

The larger risk

The immediate story is a decline of nearly 3 million marketplace enrollees. The longer-term issue is whether the country is entering a broader reversal in insurance coverage.

The enhanced subsidies were temporary, but they changed the marketplace by bringing in millions of people who had previously found coverage too expensive. Their expiration has restored the ACA’s older subsidy structure at the same time that the underlying cost of insurance and medical care continues to rise.

Additional federal changes affecting Medicaid and marketplace eligibility are expected to reduce coverage further over the next decade. The Congressional Budget Office projects that the number of uninsured Americans will increase from about 30 million in 2026 to 37 million by 2036, largely because of provisions affecting Medicaid, the Children’s Health Insurance Program and the ACA marketplaces.

For consumers, the danger is not limited to a higher insurance bill.

It is the skipped prescription, the delayed cancer screening, the specialist visit that never gets scheduled or the emergency-room bill that arrives after coverage has disappeared.

Health insurance may be one of the first items removed from a strained monthly budget. The need for health care does not disappear with it.