Between 2020 and 2025, the number of Americans who obtained affordable coverage through state and federal exchanges more than doubled, from 11.4 million to 24.3 million. Growth was even greater in some states; in Texas enrollment increased from 1.1 million people to 3.9 million. Louisiana, Mississippi, Tennessee, Georgia and West Virginia saw similarly big spikes.
By 2025, more than 90 percent of Americans enrolled in marketplace plans were benefitting from federal cost-sharing. On average, their premium costs were predicted to more than double in 2026.
For some, that would be a blessing. A self-employed couple in Connecticut told NPR their monthly premium had quadrupled from $630 to about $2,500. A Utah photographer told ABC coverage for her and her spouse rose from $495 to $2,168 — an amount about the same as her entire monthly cost of living.
Enrollment in ACA marketplaces is down by more than a million according to the Centers for Medicare and Medicaid Services, the first year-over-year decline since 2020. The Urban Institute predicts that almost 5 million people will become uninsured in 2026 as a consequence of premium increases.
Counts at this time represent people who selected plans or were renewed automatically, not those who obtained or maintained coverage. A more accurate picture will be possible in the spring, after grace periods for premium nonpayment have ended.
The number of Black families without insurance could increase as much as 24 percent in some urban areas. Americans who are older but not yet old enough (65) to be eligible for Medicare will be hit hard. Subsidies or not, a 60-year-old can already expect to pay nearly three times as much as a 21-year-old for health insurance; more than 21 million Americans are between the ages of 60 and 64. If enough healthy people decide to forgo coverage due to cost, some believe the increased risk to insurers from a greater concentration of people who actively use their policies could send premiums up even more.
Legislation to renew the subsidies didn’t make it through Congress in time to prevent their expiration, but 2026 began with hope this might still be possible. In January, the House passed a bill that would extend them for three years. Republican Sens. Bernie Moreno and Susan Collins introduced a proposal for a two-year extension, but last week Sen. Moreno said Senate negotiations were “effectively over.”
Negotiations might be over, but politics are not. A recent KFF tracking poll found that health care is the biggest household expense worry for nearly 7 in 10 Americans. Four in 10 say these costs will have a “major impact” on their decision to vote this year and the party they chose to support.
