By Isabelle Wilson-
Enrolment in the Affordable Care Act marketplace is projected to fall by nearly 5 million people this year as rising insurance costs force millions of Americans to reconsider whether they can afford health coverage, according to a new analysis that is intensifying debate over the future of the nation’s healthcare system.
The report, released Tuesday by healthcare research organisation KFF, paints a troubling picture for the insurance exchanges created under the Affordable Care Act, commonly known as Obamacare. Analysts estimate marketplace enrolment could decline by more than 20% in 2026, largely driven by soaring premiums and the expiration of enhanced federal subsidies introduced during the COVID-19 pandemic.
AD: Capeesh Restaurant
The numbers are becoming increasingly difficult to manage. KFF found that average monthly premium payments have risen by roughly $65, while deductibles have climbed by more than $1,000 compared with previous years. The sharp increases are forcing households to choose between maintaining health insurance and covering basic living expenses such as rent, groceries and utilities.
The Affordable Care Act has long served as a crucial source of health coverage for people who do not receive insurance through employers or government programs such as Medicare and Medicaid. Since its passage in 2010 under former President Barack Obama, the ACA has expanded healthcare access to millions of Americans, particularly low- and middle-income workers, freelancers and self-employed individuals.
Enrol
AD: Oysterian Sea Food Restaurant And Bar
lment reached record highs during the Biden administration after Congress approved temporary subsidy expansions designed to lower monthly insurance costs during the pandemic.
Those subsidies significantly reduced premium payments for many families and helped push marketplace participation above 24 million people nationwide. But the enhanced financial assistance expired at the end of 2025 after lawmakers failed to reach an agreement on extending the program.
Healthcare experts say the consequences are now becoming visible across the country. According to KFF researchers, many middle-income Americans are being hit hardest because they earn too much to qualify for traditional low-income subsidies but still struggle to afford unsubsidised premiums. Analysts warn this group is particularly vulnerable to dropping coverage altogether as costs continue climbing.
The report also found that while enrolment declines are occurring nationwide, states operating their own insurance exchanges appear to be retaining more participants than states relying solely on the federal HealthCare.gov marketplace.
Some states have introduced local assistance programs or additional subsidies to soften the financial blow, though experts caution those measures are unlikely to fully offset the loss of federal aid. Healthcare economists say the market faces a dangerous cycle. As healthier consumers drop coverage because of higher costs, insurance pools become older and sicker overall, increasing insurers’ expenses and potentially leading to even higher premiums in future years. Several insurers have already warned regulators about this risk in recent filings for 2026 plans.
Across the United States, families enrolled in ACA plans are already adjusting to the new economic reality. Some Americans are switching to lower-premium bronze-tier plans that carry significantly higher deductibles and out-of-pocket costs. Others are delaying medical treatment, reducing household spending or dropping insurance entirely.
The KFF analysis found that many consumers are attempting to preserve coverage “any way they can,” even if that means accepting plans with deductibles exceeding $7,000 annually. Individuals with chronic conditions often face particularly intense financial strain.
In Orlando, Florida, one ACA enrollee interviewed by the Associated Press said her monthly premium nearly tripled after the subsidy expiration. She reportedly began cutting expenses on food and social activities while delaying utility payments to keep insurance coverage needed to manage Crohn’s disease and mental health treatment.
Stories like hers are becoming increasingly common, healthcare advocates say. Recent data from Pennsylvania’s state-run exchange, Pennie, showed approximately 130,000 residents dropped ACA coverage within months after premium spikes averaging more than 100% statewide. Rural residents and older adults between 55 and 64 years old experienced some of the largest coverage losses.
Meanwhile, analysts at Wakely Consulting Group estimate that overall ACA enrollment could decline by as much as 26% this year if current trends continue. A growing share of consumers are failing to make their first premium payments after enrolling, a sign that affordability problems are deepening even among those initially attempting to keep coverage.
According to reports, roughly 14% of ACA enrollees failed to make their first payment in 2026, a dramatic increase from typical nonpayment rates seen in prior years. The political implications of the enrolment decline are also beginning to emerge.
Democrats have argued that allowing enhanced subsidies to expire has placed millions of Americans at risk of losing healthcare access. Many party leaders are now calling for renewed federal assistance and warning that rising uninsured rates could place additional strain on hospitals and emergency rooms.
However, have pointed to fraud concerns within the ACA system and argue that broader reforms are necessary to control long-term healthcare spending. The Trump administration has maintained that anti-fraud enforcement efforts contributed to some enrolment declines by removing ineligible participants from the program.
Healthcare policy analysts say affordability remains the dominant issue. Insurers across the ACA marketplace have proposed average premium increases of roughly 18% to 20% for 2026, the steepest jump in years.
Rising hospital costs, inflation, labour shortages and expensive specialty medications including high-demand weight-loss drugs and biologic therapies are among the major drivers behind the increases. Several insurers have also cited uncertainty surrounding federal healthcare policy as a reason for higher rates. Some companies warned regulators that the loss of healthier customers from the marketplace would increase financial risk and force them to raise prices further to offset expected medical costs.
Uncertain Future for Obamacare
Despite the grim projections, some experts believe the current turmoil could eventually stabilise. KFF researchers noted that insurers appear to have anticipated many of the marketplace disruptions tied to subsidy expiration and may already be adjusting pricing strategies accordingly.
Some analysts suggest the sharp increases seen in 2026 could represent a temporary “market correction” rather than the beginning of a sustained collapse.
Even so, the short-term impact could be profound. Healthcare advocates warn that millions losing insurance coverage would likely result in delayed medical care, worsening chronic health conditions and increased medical debt for vulnerable families. Hospitals and clinics, particularly in rural communities, could also face growing financial strain from higher levels of uncompensated care.
Women, minorities and lower-income workers are expected to experience disproportionate effects. Advocacy groups note that women make up more than half of marketplace enrollees and often face higher healthcare needs combined with lower average incomes than men.
The broader healthcare system may also feel ripple effects if enrolment continues declining. Economists caution that shrinking participation could weaken competition among insurers, especially in states where only a limited number of companies operate in the ACA marketplace.
Many Americans remain caught between rising healthcare costs and uncertain political solutions. Congress debates future healthcare policy and insurers finalise next year’s rates, millions of consumers are entering another year of financial anxiety over whether health insurance will remain within reach.
AD: Heritage And Restaurant Lounge Bar