People Who Rely on the ACA Marketplaces Face Mounting Affordability Challenges

Just under 23 million people selected an Affordable Care Act (ACA) marketplace plan for 2026, according to the latest data on the open enrollment period that recently closed. This is a drop of more than one million people compared to 2025. But this decline is only the tip of the iceberg. The coverage losses will almost certainly be higher because some people won’t pay their premium or won’t be able to sustain their premium payments for more than a few months. In addition, many people have selected less generous coverage for 2026 to maintain a more affordable premium, early data from state-based marketplaces suggest.

Congressional Republicans and the Trump Administration’s refusal to extend the premium tax credit (PTC) enhancements at the end of 2025 — which resulted in net premium increases of more than $1,000 on average for enrollees receiving the PTC — and a provision in 2025’s harmful Republican megabill that eliminated PTC eligibility for certain people with lawful immigration statuses starting in 2026 have set in motion a decline that will play out over the next several months or more. These changes undoubtedly raise costs and financial burdens for low- and moderate-income people, while also creating additional barriers that make it harder for people to get the health care they need. Here’s what we know right now:

• First, the data reflect people selecting a plan (not the coverage becoming effective) and include many people whose 2025 coverage was automatically renewed for 2026. For new coverage to become effective, people must pay their share of the first month’s premium. If people don’t make that payment, their coverage won’t start. People who had coverage in 2025 and were automatically re-enrolled have a 90-day grace period to pay their share of their premium before their coverage is terminated. For these reasons, the number of people actually enrolled is likely to fall compared to the number who selected plans.

  Some people may only have learned of their higher premiums in January and may no longer be able to afford their coverage. People who don’t pay their share of the premium on time will be locked out of marketplace coverage for the remainder of the year (unless they qualify for a special enrollment period), and in many cases they will be uninsured. Notably, several states offer state-funded subsidies that fully or partially offset the loss of PTC enhancements, and enrollment in these states has grown (Connecticut, Maryland, Massachusetts, New Jersey, and New Mexico) or declined less compared to the national average (California and Colorado).

  More information about how many of the 23 million people pay their premiums and maintain coverage from month to month won’t be available until July, based on the data release schedule in recent years.

• Second, some people may respond to higher premium costs by choosing less generous coverage — that is, with a higher deductible and higher cost sharing requirements — for 2026. This leaves them more exposed to high medical bills and at risk for medical debt should they need high-cost care at any point this year. More information on the plan choices people made for 2026 will be available this spring.
• Third, some people may be absorbing higher premiums, but making other sacrifices that affect their budgets and well-being, especially people with chronic conditions or known health care needs who simply cannot choose to go without insurance. People are choosing to pick up additional jobs, save less, cover fewer people in the household, and cut back on other household expenses to make ends meet. 
• Finally, a provision in the Republican megabill takes away eligibility for PTCs from hundreds of thousands of lawfully present immigrants with income below the poverty level, putting marketplace coverage out of financial reach. These are individuals whose income would generally make them eligible for Medicaid but who are barred because they do not meet Medicaid’s restrictive immigration-related eligibility requirements, despite having lawful immigration statuses. Since 2014, the ACA has filled this gap, providing access to affordable ACA marketplace coverage for people with lawful immigration statuses who have very low incomes. Ending PTC eligibility for this group will result in approximately 300,000 people becoming uninsured in 2034.

This year is only the beginning of the implementation of marketplace policy changes advanced by Republicans and the Trump Administration that will reduce access to coverage and care and increase families’ financial burden. These include even deeper cuts to immigrant eligibility for PTCs, increased verification requirements, a shorter open enrollment period, and the elimination of caps on PTC repayment. These changes are part of a broader, regressive Republican policy agenda that will cause roughly 15 million people to lose health coverage and become uninsured while also sharply limiting access to food assistance and other basic needs programs.