Why ACA enrollment has fallen by millions

Enrollment in the Affordable Care Act marketplace has fallen by millions this year, and the Trump administration and health policy experts are at odds over the reason.

The number of people enrolled in a health insurance plan purchased through the ACA marketplace decreased by approximately 3 million (or approximately 13%) to 19.2 million in February 2026, from 22.1 million at the end of 2025. data It was released last week by the Department of Health and Human Services.

First drop in ACA enrollment since then The first Trump administration and the biggest There has been a decline since ACA marketplaces were established in 2014.

The data provided the first look at “actual” enrollments since the enhanced ACA premium subsidies that lower the monthly premium cost for enrollees expire at the end of 2025. The data also reveals whether people who sign up can also make monthly payments.

Health policy experts said the drop is the clearest sign that the end of federal subsidies for ACA premiums has made insurance too expensive for many Americans and led many households to drop coverage.

The Trump administration described the decline positively: HHS pointed to anti-fraud efforts as the main driver of the recent decline.

HHS said in its latest statement that its efforts have partially resolved a massive increase in fraudulent records that occurred during the Biden administration. data broadcast. Among other things, the Centers for Medicare and Medicaid Services canceled insurance for 250,000 people enrolled in an ACA plan without their consent, the agency said.

Policy experts said there was little evidence to support the idea that preventing fraud was the primary factor.

Instead, the fraud claim provides political cover for the administration and Republicans in a midterm election year when affordability is “Americans’ top concern,” said Jonathan Oberlander, a professor of health policy and policy at the University of North Carolina at Chapel Hill.

Strengthened ACA premium subsidies were a key reason for the fall government shutdown: Democrats pushed to extend the subsidies beyond 2025, but the GOP ultimately let them expire.

The GOP also made a number of administrative changes to the ACA market in its big, beautiful bill; This suggests that projections will further reduce enrollment.

“Republicans under President Trump are working to ensure health care is affordable everywhere,” a spokesperson for the Centers for Medicare and Medicaid Services said in an emailed statement. he said. “Additionally, CMS will continue to eliminate waste, fraud and abuse wherever it occurs to protect Americans’ tax revenues,” the spokesperson said.

“The Trump Administration used numerous tools that set in motion a full-scale effort to ensure that federal subsidies went only to targeted individuals,” according to the report. report It was released June 26 by the Office of the Assistant Secretary for Planning and Evaluation within HHS.

Health policy experts do not dispute that there is measurable levels of alleged fraud in the system. Indeed, the Government Accountability Office, a nonpartisan federal watchdog that monitors government spending and efficiency, outlined the risk of fraud tied to ACA subsidies in December. report Requested by congressional Republicans.

However, experts dispute this reason, as some of the problematic activity can be explained by factors that are not legitimate or criminal.

HHS said it estimates more than 1 million current ACA enrollees do not have a Social Security number, which it classifies as “inappropriate” or “fictitious” registrations. But experts said this was not clear evidence of wrongdoing.

For one thing, many immigrants with legal visas who are legally in the U.S. and allowed under the ACA won’t necessarily have a Social Security number, said Michael Gusmano, a professor of health policy at Lehigh University.

He said immigrants in the country were already illegally barred from enrolling in the ACA plan.

More generally, there may also be data matching issues with Social Security numbers in signing up for the ACA marketplace, Oberlander said, meaning the SSN absence may be a data issue and not abuse.

Matthew Fiedler, a senior fellow at the Brookings Institution, a think tank that studies health economics and policy, said SSN deficiency can occur if brokers try to enroll “fake” enrollees — which would be fraud — but it can also occur if a broker is simply “sloppy” and chooses not to bother collecting all of an enrollee’s information.

“In fact, the reason why the Administration did not terminate these records en masse may be because they believed this group contained a large number of legitimate records,” Fiedler wrote in an email.

Oberlander was even more direct in his assessment, suggesting the layoffs were politically motivated. “The drop in enrollment is definitely not related to fraud,” he said. “[Republicans] “They are exaggerating the scope of the fraud issue to hide their health insurance coverage deductions.”

HHS said in its latest statement: report that many enrollees misrepresent their income to access these “free” ACA health plans.

But Cynthia Cox, director of the ACA program at KFF, a nonpartisan health policy research group, said this alleged misrepresentation may not have been intentional.

When people sign up for ACA coverage, they must estimate their income for the upcoming year. Cox said these estimates determine eligibility for premium subsidies, and some people, especially those with variable income, may estimate incorrectly.

In any case, they must reconcile this income on their tax returns and repay any excess subsidies.

According to HHS, the “no-fee” plans also offered a financial incentive for “unscrupulous” brokers to enroll people in ACA coverage without their knowledge to receive commissions. These people did not know that they were registered because they did not owe premiums.

HHS said CMS identified and revoked coverage for 250,000 people who signed up without their consent.

Enrollees’ premiums face an average increase of 114%, from $888 in 2025 to $1,904 in 2026, due to the end of subsidies, according to KFF. predictions last year. Some enrollees face the possibility of paying additional annual premiums of $20,000 or more in 2026, KFF said.

“It is basic economics that making something more expensive makes people less likely to buy it,” Fiedler of the Brookings Institution wrote in an email.

“There is also ample empirical evidence that when premiums increase, far fewer people buy insurance (especially among the low-income populations that Marketplaces serve),” he wrote. “So it would be a big surprise if doubling enrollees’ premiums doesn’t lead to a big drop in enrollment.”

Gusmano also said inflation in the US economy remains high.

This was a reason Decline in household earnings That makes it harder to afford health premiums, he said, after factoring in living expenses.

Policy changes in the ACA market highlighted by the Trump administration “show most of their impact before the end of 2025,” Fiedler said, meaning the big enrollment declines seen in early 2026 can’t easily be explained by fraud checks.

Experts said enrollment rates are likely to continue falling through 2026 and in future years.

About 17% of ACA returnees said they weren’t sure they could afford monthly health insurance premiums for all of 2026, according to KFF questionnaire It was published in March.

Congressional Budget Office estimated In February, total enrollment in ACA marketplace health plans will drop to 12.5 million by 2028; This means almost half of last year’s registration number. This figure will exceed enrollment by nearly 1 million in 2021, when increased subsidies come into effect.

The share of the U.S. population without health insurance is expected to rise from 7.6 percent in 2025 to 10.4 percent by the end of the decade, according to the CBO.

“This is a massive erosion of registrations in the market and we are only in the early months [of 2026]”This is just the beginning,” said Oberlander of the University of North Carolina.