Millions could lose health insurance as enhanced ACA subsidies expire

Approximately 22.8 million Americans have purchased health insurance through the Affordable Care Act marketplace so far in 2026, according to data released Monday by the Centers for Medicare and Medicaid Services. This is a decrease of about 1.5 million people from the 24.3 million people who had health insurance in 2025.

The data represents an early sign of the impact of the recent expiration of expanded premium subsidies provided by the federal government starting in 2021.

Medical experts now predict that millions of people will lose their insurance coverage due to soaring health insurance premiums. The issue could threaten Republican success in this year’s congressional midterm elections, as most of the ACA enrollment growth in recent years has occurred in red states, according to the data.

Without the enhanced subsidies, which expire at the end of 2025, the average recipient’s premiums would more than double this year, according to KFF, a health policy research organization.

Health experts credit the enhanced ACA subsidies for making insurance more affordable for consumers and significantly reducing the number of uninsured Americans since it took effect. ACA enrollment hovered around 11 million to 12 million people from 2015 to 2021, but doubled to more than 24 million by 2025 when enhanced subsidies went into effect.

Now, coverage is about to gain even more attention as millions of Americans are expected to forgo insurance altogether due to high premiums.

Jonathan Birx, executive vice president for economic and health policy at the Bipartisan Policy Center, said: “The health policy debate in recent years has actually been primarily about cost because the coverage issue has largely been resolved.” “With the expiration of the enhanced subsidies, the compensation debate has started again.”

CMS data does not yet paint a complete picture of enrollment in 2026. Health experts expect more households to lose their insurance coverage in the coming months.

First, this number does not yet cover the entire open enrollment period through January 15th. The latest CMS enrollment data is as of January 3 for states using the federal Healthcare.gov platform and as of December 27 for state-based ACA exchanges. People still have time to decide whether to register.

Additionally, this number includes people who enrolled in health insurance in 2025 and were automatically re-enrolled in the same coverage in 2026.

Experts say people may choose to cancel their insurance if they decide it’s too expensive after they start paying their first premiums in the coming weeks.

“It is too early to say how much of a decline this will ultimately be,” Jared Ortaliza, a policy analyst at KFF who focuses on the Affordable Care Act, wrote in an email. “Compared to about the same time last year, new data released by CMS shows fewer people are enrolling in ACA Marketplace plans. If this holds true by the time Open Enrollment ends, it would be the first time since 2020 that year-over-year enrollment has declined.”

Jessica Bansin, a senior fellow in the Urban Institute’s health policy division and former deputy director for health at the Congressional Budget Office, said the true impact of the expiration of the premium subsidy increase “may be murky” until mid-year.

Bansin said this is typically when CMS issues a report on “affected registrations.” Health insurance choices do not become activated, or “active,” until the enrollee pays the premium, she said.

Economists at the Urban Institute estimate that a total of 4.8 million people will lose health insurance and become uninsured by 2026 as subsidies expire.

“Given the overall rise in prices in the health care sector, the risk that health care costs will become unmanageable is real,” Birx said, highlighting the financial risks of forgoing insurance coverage.

An additional 2.5 million people have dropped their ACA coverage, but will probably find replacement coverage through employer-paid insurance or Medicaid, depending on their circumstances, said Bansin, co-author of the Urban analysis.

Experts say other insurers are expected to remain in the ACA market but enroll in higher-deductible plans with lower premiums but higher upfront costs for care.

“A good health care system means a healthy and productive workforce,” Bansin said. “If a large portion of the working-age population does not have access to health care, it ultimately has a negative impact on the economy.”

Expiring subsidies are also becoming a key political issue at a time when midterm congressional elections are nearing the end of the year and affordability is a top priority for households.

Overall ACA enrollment has more than doubled since 2020, from about 11 million to a record 24 million in 2025, according to an analysis of federal data by KFF.

Most of the enrollment growth occurred in states won by President Donald Trump in the 2024 election.

According to KFF, participants from these states accounted for approximately 88% of the total ACA market growth since 2020 (11.4 million of the 12.9 million new enrollees).

According to the KFF study, registration numbers increased by an average of 157% in states that voted for Mr. Trump, and by 36% in states that voted for former Vice President Kamala Harris. Enrollment numbers have more than tripled in Texas, Mississippi, West Virginia, Louisiana, Georgia and Tennessee.

The subsidies became the epicenter of the fight to end the record-long government shutdown that lasted from October 1 to November 12.

Democrats in Congress are pushing for an extension of the subsidy expansion, but a majority of Republicans say they oppose it.

A group of 17 House Republicans joined Democrats in voting Thursday to extend the aid. The bill faces long odds in the Republican-controlled Senate, which rejected a three-year extension in December.

President Trump has also threatened to veto such a measure.