The Real Number Is 5 Million — Not 1 Million

When open enrollment closed, the headline figure was bad but manageable: roughly 1 million fewer people signed up for ACA marketplace plans compared to 2025. Policy watchers warned that number would get worse. They were right.

A new analysis from KFF, published May 19, 2026, projects total marketplace enrollment will fall from 22 million in 2025 to approximately 17 million in 2026. That's a 5 million person drop — five times worse than the initial enrollment data indicated.

KFF's Cynthia Cox, who co-authored the report, says the analysis drew on data from the Centers for Medicare & Medicaid Services, state-based marketplace figures, KFF survey data, and estimates from Wakely Consulting Group. It also aligns closely with CMS's own internal data, as reported by NOTUS the week prior.

Why This Happened: Congress Failed to Act

The cause is straightforward. Enhanced premium tax credits — the extra federal subsidies that kept ACA premiums affordable — expired at the end of 2025. Congress came close to a deal to extend them. The deal collapsed.

"Costs went up significantly and a lot of people dropped their plans," Cox told NPR. Last fall, KFF had already projected premiums were doubling on average for many enrollees. When the bills arrived, people couldn't pay them.

People Didn't Find Better Coverage — They Found Nothing

Those 5 million people mostly didn't migrate to employer coverage or Medicaid. Cox says most of them became uninsured.

That means no doctor visits unless it's an emergency. No prescription coverage. One serious diagnosis away from financial ruin.

People who stayed on ACA plans aren't doing great either. According to Cox, those remaining enrollees are absorbing higher costs in one of two ways: paying steeper monthly premiums, or accepting higher deductibles. Often both. "A lot of people moved on to a lower level of coverage that has a much higher deductible," she said.

The ACA marketplace in 2026 has fewer people, and the people still in it are paying more for less.

What Mainstream Coverage Is Getting Wrong

Most outlets are framing this purely as a Republican failure to extend the subsidies. That's partially true — the GOP-controlled Congress let the deal die. But that framing conveniently skips several things.

First, those enhanced subsidies were always a temporary patch, created by the American Rescue Plan in 2021 and extended once. Nobody built a sustainable long-term financing structure. Congress from BOTH parties has been kicking this can for years.

Second, the underlying problem — why ACA premiums are so high in the first place — isn't getting addressed by either party. The subsidies were a band-aid over a broken pricing structure. Without them, the system falls apart. With them, it's indefinitely dependent on federal cash.

Third, the CMS already had internal data showing this collapse was coming, according to NOTUS. That information existed before this KFF analysis dropped. Congress should have been acting on CMS's own numbers weeks ago.

The Numbers Are Preliminary — But the Trend Is Clear

KFF notes that some of this data is still preliminary. Enrollment figures from state-based marketplaces continue to trickle in. The final number could shift.

But the direction is clear. Five million is the projection. CMS's internal data corroborates it. Insurer behavior corroborates it. The premium doubling KFF flagged last fall corroborates it.

What This Means for Regular People

If you dropped your ACA plan because you couldn't afford it in 2026, you are now gambling every single day. One car accident. One cancer diagnosis. One emergency surgery. That's potentially hundreds of thousands of dollars in medical debt with zero coverage backstop.

If you kept your plan, you are paying significantly more — either monthly or when you actually need to use it.

Congress will eventually revisit this. They always do, right before it becomes a full-blown political crisis. By then, millions of people will have gone months or years without coverage, racking up medical debt and delaying care they needed.