ACA enrollment falls 21.5%

The Affordable Care Act marketplace is entering 2026 with fewer enrollees and higher cost sharing after the expiration of enhanced premium tax credits at the end of 2025. AJMC reported on May 20 that marketplace enrollment is projected to drop 21.5% this year, while the average deductible for marketplace plans rises to a record $3,786. The changes are concentrated among people with higher incomes who no longer qualify for the most generous subsidies and among younger adults, according to the AJMC report. At the same time, providers are bracing for additional pressure on the safety net as the Trump administration pursues further Medicaid payment reductions, STAT reported on May 22. ### Why did enrollment fall this year? The end of 2025 brought the expiration of the enhanced ACA subsidies that had lowered monthly premiums for marketplace coverage. AJMC said the subsidy expiration took effect at the start of 2026 after Congress did not extend the assistance, leaving many consumers facing substantially higher premiums when they renewed or shopped for coverage. (ajmc.com) AJMC reported that disenrollment was concentrated among people between 400% and 500% of the federal poverty level, unsubsidized enrollees, and adults ages 18 to 34. The same analysis said some states softened the losses through supplemental subsidies and outreach, with New Mexico posting enrollment growth despite the broader national decline. (ajmc.com) ### What changed inside the plans people kept? The average deductible in ACA marketplace plans rose 37% in 2026, or more than $1,000, to $3,786, according to AJMC. The report said consumers moved toward lower-premium bronze plans, which typically carry higher deductibles and expose patients to more out-of-pocket costs before coverage becomes more generous. (ajmc.com) A March AJMC report found 80% of continuing marketplace enrollees said their cost sharing was higher than a year earlier, and 51% said it was “a lot higher.” The same report said 73% worried about affording emergency care, 49% worried about routine visits, and 45% worried about prescription drugs. ### Which patients are most exposed to higher costs? (ajmc.com) Younger adults and middle-income consumers appear to be among the groups most affected by the subsidy rollback. AJMC said the largest enrollment losses were among people who had benefited from the temporary expansion of assistance but now face higher net premiums and steeper deductibles if they stay covered. (ajmc.com) Bronze-plan migration also changes how patients use care. Higher deductibles can push people to delay routine appointments, testing, or medication fills until costs become unavoidable, a pattern reflected in AJMC’s reporting on rising concern over emergency care, office visits, and drugs. That is an inference from the cost-sharing data and patient responses reported by AJMC. (ajmc.com) ### Why are clinicians and hospitals watching this so closely? STAT reported on May 22 that the Trump administration wants to reduce Medicaid state directed payments further, expanding on cuts already contained in Republicans’ 2025 tax law. Those payments have been an important source of funding for hospitals and other providers treating Medicaid patients. (ajmc.com) The combination of thinner ACA coverage and possible Medicaid payment cuts raises the stakes for safety-net providers. If more patients arrive with higher deductibles, narrower effective access, or no coverage at all, clinics and hospitals that already treat low-income populations could face more uncompensated care and more administrative work around referrals and medication access. That is an inference based on AJMC’s marketplace findings and STAT’s reporting on Medicaid payment policy. (statnews.com) ### Which states may hold up better than others? New Mexico was cited by AJMC as a state where supplemental subsidies and outreach helped offset national enrollment losses. The report suggested that state-level policy choices can still shape affordability and retention even after the federal enhanced subsidies expired. (ajmc.com) Washington’s next health-policy fight is now centered on Medicaid financing. STAT said provider groups are preparing for a showdown with the administration over proposed cuts to state directed payments, while ACA affordability remains under pressure for 2026 marketplace enrollees. (statnews.com) (ajmc.com)