ACA enrollment drops significantly due to high premiums

In 2021, enhanced ACA subsidies were enacted to help Americans get through the COVID-19 pandemic. With these enhanced subsidies, some lower-income ACA enrollees were able to receive healthcare without premiums, and high earners paid no more than 8.5% of their income.

Although the subsidies were extended multiple times, they ultimately expired on Jan. 1 after several failed attempts in Congress to pass an extension, leading to higher healthcare costs for millions of Americans.

For example, Megan Burkett, a 49-year-old nurse practitioner, saw her ACA premiums increase from $307 per month when she qualified for a federal subsidy last year to around $2,500 per month this year. "On paper, I have a really good job and salary," Burkett said. "[But] I can't afford a second mortgage every month."

At the end of March, CMS data showed initial enrollment in ACA plans dropping by 5% in 2026 compared to 2025. In total, there were 23.1 million sign-ups during the 2026 open enrollment period, around 1.2 million fewer than in 2025.

Higher premiums have likely led more people to drop their ACA plans. According to a recent analysis from Wakely Consulting Group, around 14% of people who enrolled in ACA plans this year did not pay their first monthly bill, with the number increasing to 25% or more in some states. Normally, the rate of falloff for ACA plan membership early in the year is much lower, only reaching mid-single digits.

Between 2021 and 2025, the percentage of premium payments that were over $500 after subsidies was 4% to 6%. However, this number has since doubled to 8%. According to insurers and state officials, early retirees with middle-class incomes have seen the largest increases in premiums, reaching $1,000 a month or more in some markets.

"It is simply because the cost of health insurance is more than what they can afford," said Pam Kehaly, CEO of Blue Cross Blue Shield of Arizona. In 2025, the insurer only lost around 2% of its ACA enrollees to nonpayment, but this number has increased to over 30% this year. 

Currently, many insurers and analysts estimate that overall ACA enrollment will decline by around 20% this year, dropping from 24 million people to 19 million people. However, some estimates project that the decline in enrollment will be even higher, reaching more than 25%.

So far, the Trump administration has downplayed the decline in enrollment, with CMS officials calling the current numbers a success. "The marketplace remains strong and resilient, continuing to provide millions of Americans with access to high-quality, affordable health care coverage options," said Chris Krepich, CMS' director of communications.

"I was spending so much money and we don't even use this because we're healthy," Balcerzak said. Instead, Balcerzak and her husband joined a medical cost-sharing cooperative Zion HealthShare for $297 per month while she signed her three children up for New York State's Child Health Plus plan, which provides low-cost coverage for children without other insurance. Overall, Balcerzak pays $970 less per month than she would have on her employer's plan.

However, if young, healthy people continue to leave their employer-sponsored health plans, this could lead to higher costs for other employees. Employers typically rely on younger, healthier workers to pay premiums and file relatively few claims to keep health plans sustainable. 

"Every single person that opts out creates this lopsided situation where they cannot sustain the costs and at some point it breaks," Cleary said.

Employers are also looking for ways to manage growing healthcare costs. According to research from Mercer, the total cost of health plans per employee will increase by 6.5% in 2026, which is the highest rate in over 10 years. In addition, around half of large employers say that these cost increases are pushing them to raise deductibles or exclude certain expensive treatments, such as GLP-1 drugs for weight loss.