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Millions of Americans are at risk of losing health insurance coverage after enhanced Affordable Care Act premium subsidies expired at the end of 2025, pushing monthly costs sharply higher for many households. Early federal data already shows a significant pullback in enrollment, with health policy experts warning that the full impact will become clearer as the year progresses.

About 22.8 million people have signed up for 2026 health insurance through the ACA marketplaces so far, according to data released by the Centers for Medicare and Medicaid Services. That figure is down roughly 1.5 million from the 24.3 million people enrolled for 2025, making it an early indicator of the fallout from the subsidy lapse.

Premium shock begins to hit enrollment

The enhanced federal subsidies, introduced in 2021, significantly lowered monthly premiums and helped fuel a historic expansion in ACA coverage. Their expiration has reversed that trend. Without the additional support, the average ACA enrollee is expected to see premiums more than double in 2026, according to health policy analysts.

From 2015 through 2021, ACA enrollment hovered between 11 million and 12 million people. After enhanced subsidies took effect, enrollment surged, reaching a record high of more than 24 million by 2025. With premiums now rising sharply, experts expect many households to reconsider whether they can afford to stay insured.

“The coverage challenge had largely been solved, and the debate shifted to costs,” said Jonathan Burks of the Bipartisan Policy Center. “The expiration of these subsidies has reopened the coverage debate in a very real way.”

Early data may understate the full drop

The current CMS figures do not yet reflect the full enrollment picture. Open enrollment runs through Jan. 15, and many of the reported signups include people who were automatically re-enrolled from 2025 plans. Those enrollees must still pay their first premium to activate coverage, and many may drop their plans once they see higher monthly bills.

In addition, the most recent data reflects enrollment only through early January for federally run exchanges and late December for state-based marketplaces. Historically, some coverage losses do not appear until months later.

Analysts caution that the true decline will not be visible until midyear, when CMS releases its “effectuated enrollment” report, which counts only individuals who have paid premiums and activated coverage.

Millions expected to become uninsured

Independent estimates suggest the impact could be substantial. Economists at the Urban Institute project that about 4.8 million people will lose health coverage and become uninsured in 2026 as a direct result of the subsidy expiration.

Another estimated 2.5 million people are expected to leave ACA plans but find alternative coverage, such as employer-sponsored insurance or Medicaid, depending on eligibility. Others may remain in the ACA marketplace but downgrade to high-deductible plans that carry lower premiums but significantly higher out-of-pocket costs.

Health experts warn that dropping coverage exposes households to serious financial risk at a time when medical costs continue to rise faster than overall inflation.

“The risk of facing an unmanageable medical bill is very real,” Burks said. “That risk increases dramatically when people are uninsured.”

Economic consequences extend beyond households

Beyond individual finances, experts say widespread coverage losses could have broader economic implications. Reduced access to health care can affect workforce productivity, increase emergency care costs, and strain hospitals and state budgets.

“A healthy workforce is essential for a productive economy,” said Jessica Banthin of the Urban Institute. “If large numbers of working-age adults lose access to care, that ultimately weighs on economic growth.”

Political pressure intensifies

The subsidy expiration is also emerging as a major political issue ahead of congressional midterm elections. ACA enrollment growth since 2020 has been concentrated in states that voted for President Donald Trump in the 2024 election.

Data shows that about 88 percent of the marketplace enrollment growth since 2020 occurred in those states. Enrollment rose an average of 157 percent in states carried by Trump, compared with a 36 percent increase in states that voted for former Vice President Kamala Harris. In states such as Texas, Georgia, Tennessee, Louisiana, Mississippi, and West Virginia, enrollment more than tripled.

Democrats have pushed to extend the enhanced subsidies, arguing they are critical to maintaining coverage and controlling household costs. Most Republicans have opposed the extension, citing budget concerns, though a group of 17 House Republicans recently broke ranks to support a temporary continuation.

The proposal faces an uphill battle in the Senate, which rejected a multi-year extension late last year. As premiums rise and coverage drops, the issue is likely to remain front and center for voters weighing affordability, health security, and economic stability.

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