Health Coverage Tracker: Millions of People Are Losing Coverage Following 2025 Republican Policy Changes
Some 2.2 million fewer people were enrolled in the Affordable Care Act (ACA) marketplaces as of February 2026 compared to December 2025, after Republicans chose to not extend premium tax credit (PTC) enhancements in the 2025 reconciliation law. Millions more people have seen their cost of coverage rise. And many others will lose ACA marketplace coverage throughout 2026, 2027, and 2028, as monthly premiums stack up and harmful marketplace policies in the 2025 Republican reconciliation law and new Trump Administration regulations take effect.
For Medicaid, 2027 is expected to kick off the most significant coverage losses due to the reconciliation law. That’s when policies like more frequent (and burdensome) eligibility renewals and a harsh work requirement will take people’s coverage away. The law further narrows immigration-related eligibility, taking health coverage away from even more people with lawful statuses, beginning in October 2026. And Nebraska and Montana are implementing the work requirement early, with Nebraskans losing coverage beginning in August 2026 (Montana plans to delay coverage loss until January 1, 2027). Other significant Medicaid cuts are scheduled for 2028. The Congressional Budget Office (CBO) projects that it will take several years for the full impacts of many policies to be felt. Even so, 4.8 million fewer people had Medicaid in May 2026 than in May 2025.
ACA Marketplace Enrollment Dropping After Premium Tax Credit Enhancements Allowed to Lapse
Medicaid Enrollment Declining; Drops Likely to Steepen After 2027
Change in enrollment from
See Chart Notes below for details on data sources.
Marketplace enrollment includes enrollees with an active plan who have also paid their monthly premium.
Open enrollment shows the number of people who selected plans during the annual open enrollment period, including some who did not subsequently pay their premium and maintain an active plan.
Source: CBPP calculations from Centers for Medicare & Medicaid Services (CMS) and state program data.
This tool tracks declines in the number of people enrolled in the ACA marketplaces and Medicaid: two sources of coverage that have been crucial to delivering affordable health care to people with low and moderate incomes. All told, CBO projects that roughly 15 million people will lose health coverage and become uninsured by 2034 due to the 2025 reconciliation law, the decision to let PTC enhancements expire, and other harmful ACA marketplace rule changes made by the Trump Administration.
ACA marketplace enrollment more than doubled from 2021 to 2025, when PTC enhancements were in effect. But those enhancements expired December 31, 2025, causing out-of-pocket premiums to spike and millions of people to drop coverage or switch to higher-deductible plans. Enrollment dropped by 2.2 million people, or 10 percent, in just the two months after December 2025. The February 2026 enrollment count was down 3 million people (13 percent) compared to the same month in 2025. Enrollment losses were far smaller in states that offer supplemental state subsidies that partially cushion the loss of federal PTC enhancements, and enrollment increased by 8 percent in New Mexico, the only state with subsidies designed to fully replace PTC enhancements. Overall, enrollment losses are expected to continue in 2026 as expensive monthly premiums stack up, and a myriad of other harmful marketplace policies that worsen affordability and cause people to drop coverage take effect in the 2026-2028 period.
Medicaid enrollment rose rapidly following the COVID-related continuous coverage protection, implemented in March 2020 to ensure people could maintain coverage during a widespread health emergency. Enrollment steeply declined after the April 2023 unwinding of that provision. It appeared to stabilize in the second half of 2024, but declines grew steeper beginning in the spring of 2025. Enrollment fell by 4.8 million people, or about 7 percent, in the 12 months from May 2025 through May 2026, according to federal government data. Enrollment has continued falling in 33 of the 40 states that have posted their own data beyond May 2026 (some as late as August 2026). However, trends vary widely across states. Much larger enrollment losses are expected to begin in 2027, especially for the 41 states (including the District of Columbia) with expansion enrollees who will be subject to the reconciliation law’s work requirement.
State Trends
MedicaidACA Marketplace Enrollment in
Marketplace enrollment includes enrollees with an active plan who have also paid their monthly premium.
Open enrollment shows the number of people who selected plans during the annual open enrollment period, including some who did not subsequently pay their premium and maintain an active plan.
Source: CMS and state program data.
Percent Change in
Click on date axis labels to change the baseline.
Marketplace enrollment includes enrollees with an active plan who have also paid their monthly premium.
Open enrollment shows the number of people who selected plans during the annual open enrollment period, including some who did not subsequently pay their premium and maintain an active plan.
Source: CMS and state program data.
Several provisions of the 2025 Republican reconciliation law and rule changes by the Trump Administration will result in more people losing coverage in the ACA marketplaces, compounding the dramatic coverage losses caused by expiration of PTC enhancements in December 2025. Starting in 2026 and 2027, the law strips PTC eligibility from many lawfully present immigrants, with those provisions alone causing a projected 1.2 million people to lose coverage and become uninsured by 2027. A host of other marketplace policies in both the reconciliation law and recent marketplace rules will raise health care costs while making it harder to get and keep coverage, with implementation throughout the 2026-2028 period.
While the reconciliation law’s biggest Medicaid coverage changes occur in 2027 and focus on expansion enrollees, particularly the work requirement and the six-month renewal requirement, other provisions begin in different years and will reduce coverage for multiple categories of enrollees. These provisions include restrictions on federal funding for most categories of immigrants living lawfully in the U.S., beginning in October 2026, as well as new limits on how states can fund their Medicaid programs.
Affordability Challenges Push ACA Marketplace Enrollees Into Plans With Higher Deductibles and Other Cost Sharing
Marketplace open enrollment plan selections by metal level in
Source: CMS data
Faced with steep increases in premiums due to the expiration of PTC enhancements, many enrollees shifted into less generous, higher-deductible bronze plans. Marketplace plans are tiered as bronze, silver, gold, and platinum. Bronze plans have the lowest premiums but the highest deductibles and other cost-sharing requirements, while platinum plans have the highest premiums but lowest cost sharing.
Historically, silver plans have been by far the most popular choice, offering a balance between premiums and deductibles and providing low-income enrollees with federal cost-sharing reductions that help with out-of-pocket costs. But in 2026, for the first time since the ACA marketplaces were established in 2014, fewer than half of marketplace enrollees selected silver plans, opting instead for less generous plans. States that offer supplemental subsidies that partially offset the loss of PTC enhancements saw a smaller drop in silver plan selections, on average, with several showing increases in silver plan selections.
Download the data: https://apps.cbpp.org/health5-18-26/data/source_data.xlsx