Far more people than previously known have dropped Affordable Care Act health insurance for 2026, according to data released Friday.
Five million fewer people are currently enrolled in ACA marketplace plans compared to the record high reached last year. More than 1 million fewer people picked a plan for 2026, and then 4 million more either disenrolled or failed to pay their premiums and, therefore, dropped coverage.
Prices in the market skyrocketed after President Donald Trump and Republicans in Congress failed to extend extra financial help for enrollees last year. The Department of Health and Human Services published a report about the data on its website Friday.
The report says 19.2 million people are currently enrolled in ACA insurance now.
At its high, 24.2 million people were in the ACA marketplace in 2025, according to government figures.
The steep drop in enrollment reflects what insurers, administrators and other health policy experts expected earlier this year. After initial sign ups were lower than last year, they predicted the picture would get worse as time went on and people found they could not afford to pay their premiums.
"The main takeaway is that enrollment is down 13% from last year," explains Cynthia Cox, director of KFF's Program on the ACA. "While the Trump administration attributes this drop in enrollment to their attempts to address fraud, this coverage loss happened at the same time millions of people faced double- or even triple-digit increases in their premium payments with the expiration of enhanced tax credits."
The idea that the growth in enrollment was due to massive fraud is a theory advanced by the Paragon Health Institute, a conservative think tank influential in the Trump administration.
Many health policy experts are skeptical. They say the increase in enrollment during the pandemic is not suspicious. It was a predictable consequence of Congress's investment of billions of federal dollars in making premiums more affordable — the enhanced premium tax credits.
"The marketplace doubled in size during the period when there were enhanced subsidies because the coverage was much more affordable and much more appealing to people," Cox says.
This year's drop in enrollment is also predictable, given that premium costs doubled, on average, from 2025 to 2026. The costs went up after Republican lawmakers let the enhanced premium tax credits expire; Democrats shut down the government in October 2025 trying to negotiate an extension of the credits that would have kept prices low.
"When their costs went up, many of them dropped their coverage," Cox says.
She adds that while fraud is a real problem in the ACA marketplaces, as it is in all insurance markets, she thinks it does not account for all of the drop in enrollment.
Stacey Pogue, senior research fellow at the Georgetown Center on Health Insurance Reforms, agrees.
"I don't see data that point to that conclusion that a 5 million-person drop can be explained by allegations of fraud," she says. "There's lots of evidence pointing to people making decisions based on what they can pay each month."
The higher health insurance costs are tough for consumers in an economy still plagued by overall inflation. As congress let the prices go up, people made tough decisions about family budgets, where to work, whom to marry and more.
It's also a problem 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," Cox says.
That's especially true because the people dropping their coverage tend to be healthier people. If too many healthy people drop out of the markets, there's a danger that the markets could enter a "death spiral."
Cox says she's not worried about a death spiral at this point.
"I think there are still enough people buying ACA marketplace coverage and that's going to keep these markets working," she says. "At this point, we don't see any parts of the country that are at risk of having no insurance company. If that were to happen, that would be what a death spiral might look like."
Even so, the premiums for these plans are on track to keep rising, which could continue to pummel consumers navigating high health care costs. Enrollment in the marketplaces may continue to shrink too. According to a recent analysis from Pogue at Georgetown, early insurance rate filings for 2027 show that rates will be going up again next year.
