Why ACA enrollment has dropped by the millions

Enrollment in the Affordable Care Act’s marketplace has dropped by millions this year — and the Trump administration and health policy experts aren’t sharing the cause.

The number of people enrolled in the ACA’s marketplace health insurance plan has dropped by nearly 3 million people — or, about 13% — to 19.2 million in February 2026 from 22.1 million by the end of 2025, according to data released last week by the Department of Health and Human Services.

It was the first drop in ACA enrollment since the first Trump administration, and the largest drop since the ACA marketplaces were established in 2014.

The data provided the first look at “effective” enrollment since the expiration of the ACA’s enhanced premium subsidies at the end of 2025, which has lowered the cost of enrollees’ monthly premiums. The data tells whether the subscribers were able to make monthly payments.

Health policy experts said the cuts are a clear sign, however, that the loss of federal subsidies for ACA premiums is making insurance more expensive for many Americans, leading more families to lose their money.

The Trump administration explained the decline in a positive way: HHS pointed to its efforts to crack down on fraud as a major driver of the recent decline.

Its efforts have partially stemmed the massive increase in fraudulent registrations that occurred during the Biden administration, HHS said in its latest data release. Among other things, the organization noted that the Centers for Medicare & Medicaid Services canceled the enrollment of 250,000 people enrolled in the ACA program without their consent.

Policy experts said there was little evidence to support the idea that fraud was the main cause.

Instead, the fraud controversy provides political cover for the administration and Republicans in the midterm election year, at a time when affordability is “a concern of the American people,” said Jonathan Oberlander, a professor of politics and health policy at the University of North Carolina at Chapel Hill.

The ACA’s enhanced premium funding was a key reason for the government shutdown in the fall: Democrats pushed to extend the funding beyond 2025, but the GOP ultimately allowed it to expire.

The GOP is also making several administrative changes to the ACA marketplace in the so-called big positive bill, which it suggests will reduce enrollment.

“Republicans, under President Trump, are working to deliver health care across the country,” a spokeswoman for the Centers for Medicare & Medicaid Services said in an emailed statement. “Furthermore, CMS will continue to root out waste, fraud, and abuse wherever it is found to protect the American people’s tax dollars,” the spokesperson said.

HHS said it estimates “improper, unclear and fraudulent enrollment” to peak at 5.6 million people by 2025.

“Program integrity efforts” by the Trump administration — such as ending certain special enrollment periods and canceling policies it deemed fraudulent — reduced such enrollment by millions, its data release said.

“The Trump administration has used multiple tools to coordinate a comprehensive effort to ensure that federal funding goes only to those it is intended for,” according to a report released June 26 by the Office of the Assistant Secretary for Planning and Evaluation, within HHS.

Health policy experts do not dispute that there has been some level of measurable fraud in the system. Indeed, the Government Accountability Office – a nonpartisan federal watchdog that studies government spending and efficiency – highlighted the risk of fraud linked to ACA funding in a December report requested by congressional Republicans.

But experts dispute the cause, as some of the problematic activities can be explained by legal or non-criminal factors, they say.

HHS said it estimates more than 1 million ACA enrollees currently do not have a Social Security number, which it classifies as “invalid” or “phantom” enrollment. But experts say this is not clear evidence of wrongdoing.

For one thing, many legally introduced immigrants to the US with legal visas who are eligible for the ACA will not have a Social Security number, said Michael Gusmano, a health policy professor at Lehigh University.

Illegal immigrants were already barred from signing up for the ACA program, he said.

More broadly, there may also be problems matching data with Social Security numbers in ACA marketplace enrollment — meaning the lack of an SSN may be a data problem, not a malpractice, Oberlander said.

The lack of an SSN can arise if sellers try to sign up “spoof” registrants – which could be fraudulent – but it can also happen if the seller is simply “careless” and chooses not to bother collecting all of the registrant’s information, said Matthew Fiedler, a senior executive at The Brookings Institution, a think tank that studies economics and health policy.

“Indeed, the reason the Administration has not simply ended this mass enrollment may be that they believe this group includes many legitimate enrollees,” Fiedler wrote in an email.

Oberlander was more specific in his assessment, suggesting that the termination was politically motivated. “The drop in subscribers has nothing to do with fraud,” he said. “[Republicans] they exaggerated the extent of the fraud to cover up the cuts they made to health insurance.”

Enhanced premium subsidies, which Congress temporarily enacted through 2021, allowed low-income families — those at 100% to 150% of the federal poverty line — to access certain ACA health plans without paying a monthly premium.

HHS said in its latest report that many enrollees had written off their money to access these “free” ACA health plans.

However, this misrepresentation may not have been intentional, said Cynthia Cox, director of the ACA program at KFF, a nonpartisan health policy research group.

When people sign up for ACA coverage, they must measure their income next year. These ratings determine their eligibility for premium financing — and some people, especially those with variable incomes, may guess wrong, Cox said.

In either case, they must include that income on their tax returns and repay the excess subsidy.

The “free” plans also provided a financial incentive for “unscrupulous” consumers to sign people up for the ACA without their knowledge, in exchange for a commission, according to HHS. Because they did not owe the premium, such people did not know they were registered.

CMS identified and canceled the enrollment of 250,000 people who were enrolled without permission, HHS said.

Health policy experts point to sharp increases in ACA insurance premiums — following the end of enhanced subsidies at the end of 2025 — as the most likely driver of declining enrollment.

Enrollees faced an average increase in their premiums of 114% — to $1,904 in 2026 from $888 in 2025 — because of the loss of funding, according to KFF estimates last year. Some enrollees face the prospect of paying an additional $20,000 or more in annual premiums by 2026, KFF said.

“It is basic economics that making something more expensive makes people less likely to buy,” wrote Fiedler, of The Brookings Institution, in an e-mail.

“And there is a lot of evidence that when premiums go up, fewer people buy (especially in the low-income people served by the Marketplaces),” he wrote. “So if the doubling of enrollee premiums didn’t lead to a significant drop in enrollment, that would be a big surprise.”

Additionally, inflation in the US economy remains high, Gusmano said.

That created a drop in household income after accounting for the cost of living — making it harder to pay health premiums, he said.

The policy changes in the ACA marketplace that the Trump administration highlighted “had a significant impact before the end of 2025,” meaning that the large drop in enrollment rates seen in early 2026 cannot be easily explained by fraud controls, Fiedler said.

It is likely that enrollment will continue to decline in 2026, and in the years to come, too, experts say.

About 17% of returning ACA enrollees said they did not feel confident they would be able to afford their health insurance monthly through 2026, according to a KFF survey published in March.

The Congressional Budget Office estimated in February that the number of enrollments in health plans in the ACA’s marketplaces would drop to 12.5 million by 2028 — about half of last year. That will still exceed enrollment in 2021, when the enhanced funding takes effect, by about 1 million people.

The share of the US population without health insurance is expected to grow from 7.6% in 2025 to 10.4% by the end of the decade, according to the CBO.

“It’s a massive drop in market enrollment – and we’re only in the early months [of 2026],” said Oberlander, of the University of North Carolina. “This is just the beginning.”