In Washington, when a policy expires, there is a specific kind of silence. There would be no press conference, no backward ribbon-cutting, just the silent passing of a date on a calendar. The enhanced premium tax credits for the Affordable Care Act marketplaces ran out at the end of the previous year. By spring, the figures began to reflect what Congress refused to acknowledge.
Up to five million people who purchase health insurance through the ACA marketplaces may discontinue their coverage in 2026, according to a new KFF analysis released this week. That is not an arbitrary projection. It uses proprietary payment numbers from Wakely Consulting Group, state exchange reports, and data from the Centers for Medicare & Medicaid Services. Plan sign-ups during open enrollment already decreased by over a million, reaching 23.1 million, the biggest decline the marketplaces have ever seen in a single year. And the story doesn’t end with sign-ups.
Effectuated enrollment—those who genuinely pay their premiums and stick with their plan—is the true indicator. According to KFF, that number could drop from 22.3 million in 2025 to roughly 17.5 million this year, potentially as low as 16.5 million. It seems reasonable that about 86% of January enrollees paid their first month’s premium, but keep in mind that attrition tends to creep through a year like this. In February, bills are delivered. In March, something goes wrong. The math becomes more difficult by summer.
Even though the politics surrounding it are never clear, what changed is. First approved in 2021 under the American Rescue Plan and extended through 2025 by the Inflation Reduction Act, the improved subsidies made coverage truly affordable for millions of people, including previously priced-out middle-class households. The premiums increased dramatically after those credits expired. According to KFF, average monthly premium payments increased from $113 to $178, a 58% increase. That number is actually less than the 114 percent increase the organization anticipated, but only because so many people left or downgraded to more affordable, higher-deductible plans.
A revealing location is where the walking-away is concentrated. Although they only made up 3% of plan selections last year, those who make between 400 and 500% of the federal poverty level—the group just above the previous subsidy cliff—account for 27% of the decline in sign-ups. These are not the enrollees with the lowest incomes. They are small business owners, nurses, and contractors—the kinds of households that politicians like to mention but then forget. The math just stopped working for them.
In all of this, the deductible figures may be the most subtle scandal. At a record $3,786, the average ACA marketplace deductible increased by 37%, or about $1,027 per person. Due in large part to enrollees switching from silver plans with cost-sharing reductions to bronze plans, which technically count as coverage but function more like catastrophic insurance with a friendlier name, it is the steepest single-year increase the marketplaces have seen.
Late last year, Congress nearly reached an agreement to extend the enhanced credits, but it fell through. Speaking with anyone in this area of health policy gives the impression that no one is entirely certain of what will happen next. The federal HealthCare.gov system is failing to retain enrollees as well as state-based exchanges with their own subsidy programs and more aggressive outreach, indicating that the gap between blue-state and red-state coverage is set to grow in ways that will take years to fully manifest.
It is difficult to ignore the pattern. For over ten years, the ACA has withstood attempts at repeal, legal challenges, and political theater. Something quieter, a tax credit that just expired, and a nation gradually adjusting to living with less coverage once more could ultimately undermine it.