ACA marketplace enrollment decline puts coverage affordability in focus

The Trump administration released updated 2026 enrollment figures for Affordable Care Act (ACA) marketplace plans, arguing that the year-over-year decrease resulted from efforts to crack down on fraud.

Enrollment fell from 22.1 million at the end of 2025 to 19.2 million in February 2026.^a The drop-off largely reflects reductions in improper enrollment rather than in consumer demand, according to the administration.

Issued by the office of HHS’s Assistant Secretary for Planning and Evaluation (ASPE), the new report is not a neutral actuarial assessment but rather a discussion of policies and trends that, in the administration’s view, led to bloated demand for ACA marketplace plans. Those policies coincided with implementation of enhanced subsidies for buying the plans.

Congress allowed the expanded subsidies to expire this year, triggering a year-over-year spike in premiums. Recent research by KFF identified an average increase of 58%, from $113 to $178 per month.

“This is lower than the 114% increase KFF projected if everyone had stayed in the same plan because many people bought down to higher-deductible plans and because those just past the subsidy cliff with the steepest increases dropped ACA coverage at higher rates,” the analysis states, referring to people with incomes between 400% and 500% of the federal poverty level (FPL).

Administration cites reductions in improper enrollment

Improper enrollments totaled 5.6 million in 2025 before dropping to 2.6 million for 2026 amid increased subsidy verification checks and other program integrity measures, according to the ASPE report.

The report states that enrollment grew by 12.9 million between 2021 and 2025, the years when the enhanced subsidies were in place. Of that increase, 7.6 million (59%) were households earning between 100% and 150% of FPL. Those households were newly eligible for $0 ACA silver plans.

“Zero-premium plans were never part of the ACA [marketplace] design and create incentives for fraud,” the report states, specifically referring to brokers who had incentives to enroll people without their knowledge or consent.

As one indication that some zero-premium enrollees never knew they were in a plan, the ASPE report says 40% had no medical claims in 2024. That compares with under 25% in other plans.

“Media reports have focused narrowly on plan cancellations, a routine phenomenon that occurs primarily in the beginning of plan years as individuals are often auto-reenrolled into plans they may no longer want or need,” the ASPE report states. “These reports largely ignore the broader landscape, including that an estimated 2.9 million improperly enrolled individuals have been removed due to various program integrity measures.”

The report posits that relative to 2019, when enrollment was 10.4 million, 6.1 million new enrollees represent legitimate additions to the ACA marketplaces, including 2.3 million who moved over from Medicaid and 2 million who previously were uninsured. With Medicaid tightening eligibility in upcoming years due to One Big Beautiful Bill Act provisions, the marketplaces may be less of an option under current policies.

Program integrity changes target improper enrollment

The ASPE report lists what it describes as errant policies by the Biden administration with respect to the ACA marketplaces, including reduced income verification requirements and relaxation of other measures intended to confirm eligibility. Oversight was also diminished in areas such as checking for dual enrollment between marketplace plans and Medicaid.

“Removing eligibility verifications enabled potential abuse of $0 premium plans,” the report states.

Expanded enrollment periods, including a longer open enrollment and year-round special enrollment periods (SEPs) for low-income individuals, also fostered improper enrollment, per the report.

A 2025 rule updating regulations for the marketplaces sought to address those issues, according to the new report. The rule had provisions to reinstate stronger verification requirements, limit SEPs and require a $5 monthly premium until an enrollee’s eligibility for a $0 premium plan is confirmed.

Municipalities filed litigation challenging several of those provisions, however, and a ruling issued by a federal court this month has vacated the provisions (barring a reversal on appeal).

Enrollment composition raises risk-pool concerns

The ASPE report does not directly address the composition of 2026 plan enrollments.

Looking at the 1.2 million decrease in open-enrollment sign-ups from 2025 to 2026, KFF reported that 542,000 (46%) were among people ages 18 to 34. The loss of younger, healthier enrollees is one of the issues leading insurers to reconsider their presence in the marketplaces.

The share of enrollments in silver plans fell from 57% to 43%, according to the KFF report, while bronze-plan enrollment jumped from 30% to 40%. Enrollment in gold plans edged upward as well, from 13% to 17%.

Average deductibles increased by 37%, or $1,027 per person, reaching a record high of $3,786.

Consumer advocate points to affordability and coverage loss

KFF notes that enrollment could fall to between 16.5 million and 17.5 million over the course of 2026, based on projections of people’s ability to continue paying their premiums.

Consumer advocacy groups disputed the ASPE report, saying the enrollment decrease is not primarily an issue of program integrity but instead reflects a coverage void.

Families USA noted that February enrollment dropped by 3.9 million relative to the number of prospective enrollees who selected a plan or were auto-renewed going into 2026. Whereas the Trump administration said the decline suggests a culling of improper enrollments, Families USA said it illustrates the prohibitive cost of marketplace plans.

“The administration’s efforts to explain away millions of Americans losing coverage with far-fetched claims of fraud and phantom enrollees is an insult to every person became uninsured or underinsured,” the organization said in a statement by Anthony Wright, executive director. “The math is simple: Congress made health coverage more expensive, and millions of real people can no longer afford it.”

Footnote

a. The 22.1 million enrollment figure, down by 2.2 million from the Biden administration’s reported tally in January 2025, represents 2025 effectuated enrolment, meaning people who remained in their plan throughout the year.