ACA exchange enrollment likely to decline by at least 17% this year: KFF

By Paige Minemyer / May 19, 2026

Enrollment in Affordable Care Act marketplace plans could decline to 17.5 million people this year, according to a new KFF analysis.

Researchers at KFF analyzed data from Wakely Consulting Group, which tracks the exchanges, and found that 86% of people enrolled in an individual market plan as of January 2026 paid their first month's premium. The consultants estimate that enrollment in the exchanges could decrease by 17% to 26% over the course of 2026, accounting for unpaid premiums, mid-year attrition and other impacts.

Based on that projection, KFF's analysts estimate that 4.8 million could drop out of their exchange plans compared to 2025. The latest enrollment data from the Centers for Medicare & Medicaid Services ends with open enrollment and shows 23.1 million enrollees, which KFF said is the "sharpest single-year drop" since the exchanges launched.

"Effectuated enrollment (the number of people who pay premiums and maintain effective coverage) is expected to fall even further than previous years as 2026 unfolds and many enrollees are unable to afford higher premium payments without enhanced tax credits, signaling significant midyear attrition on top of already declining sign-ups," the researchers wrote.

Sign-ups for ACA coverage grew significantly following the rollout of enhanced premium tax credits as part of the COVID-19 recovery response in 2021. Effectuated enrollment for 2025 hit an all-time high of 22.3 million, more than double the number of enrollees in 2017, which was 9.8 million.

A 4.8 million decline represents the mid-point of Wakely's estimated range, or 21.5%, KFF said. At the low end, 3.8 million would drop out of coverage, and at the high end, coverage losses would be 5.8 million.

These estimates align with projections from the Congressional Budget Office, as well as with federal data recently made public by the news outlet NOTUS, the KFF analysts said.

In addition, a KFF poll released in February found that 17% of individuals who returned to the ACA markets for 2026 said they were unsure they could afford their premiums for the entire year.

Data suggest that close to half of those who have dropped their ACA plans are on the subsidy "cliff," where they earn more than 400% of the federal poverty lever (FPL) and thus do not qualify for tax credits on marketplace plans. The enhanced subsidies, which expired on Jan. 1, would benefit people in that earnings bracket, so they may have earned enhanced tax credits prior to 2026.

People who earn between 400% and 500% of the FPL represented just 3% of sign-ups for 2025, but account for 27% of the decline in sign-ups from 2025 to 2026, KFF said. Individuals earning more than 500% of the FPL accounted for 21% of the decrease, per the study.

The study also found that declines among individuals aged 18 to 34 were the largest of any age group.

Enrollment declines varied significantly between states, with sign-ups decreasing in 41 states for 2026. The largest decrease was seen in North Carolina at 22%, the only state with a decline of over 20%.

Average premiums for marketplace plans grew by 58% on average between 2025 and 2026, increasing from $178 and $113. KFF previously estimated that premiums could spike by 114%, but the researchers said that increase was lower as more people chose bronze tier plans, which generally have lower premiums and higher deductibles, and that many people on the "subsidy cliff" chose to exit the market entirely.

Given these shifts, the share of people in bronze plans increased from 30% in 2025 to 40% in 2026, driving up average deductibles to a record high. The average deductible for a marketplace plan grew from $2,759 to $3,786, or about 37%.

Without a large shift toward the bronze tier, KFF said that deductibles in 2026 would have instead risen by 6% on average.

The researchers said that federal data on effectuated exchange enrollment will only include aggregate data, not demographic and plan-level information. CMS also offered a grace period through March for individuals to pay their first premium, and data from that window may be a year out.

"As a result, a complete picture of how the expiration of enhanced premium tax credits reshaped who has coverage and what kind of plan they hold may not be available for some time," they wrote.