Nearly three million fewer people were enrolled in an Affordable Care Act marketplace plan in early 2026 than a year earlier, and the households that kept their coverage watched their monthly premium bill climb sharply at the same time. The two trends line up on the calendar: enhanced federal premium tax credits that had capped many households’ costs expired at the end of 2025, and enrollment fell as those credits disappeared. For a family that buys its own health coverage rather than getting it through a job, the change shows up first on a monthly statement, not in a federal enrollment count.
Premium Payments Jumped 58 Percent for Those Who Stayed
Effectuated marketplace enrollment — meaning people who actually paid their first premium and kept coverage active, not simply everyone who selected a plan during sign-up — fell from a high of 22.1 million in February 2025 to 19.2 million in February 2026, a drop of about 13 percent, according to newly released federal data. The decline coincided with a sharp rise in what enrollees actually paid each month once enhanced subsidies stopped covering as much of the bill.
The average marketplace premium payment after subsidies rose 58 percent, from $113 to $178 a month, according to a KFF analysis of the federal enrollment data, while average deductibles climbed 37 percent, adding more than $1,000 per person in potential out-of-pocket costs before a plan starts paying claims. A follow-up KFF survey of returning marketplace enrollees found that 44 percent said their higher insurance costs had made it harder to afford basic necessities such as groceries, utilities, or rent, and 17 percent said they were not confident they could keep paying their premium for the rest of the year.
A separate issue brief from the Department of Health and Human Services puts February 2026 marketplace enrollment at the same 19.2 million figure, but attributes roughly 2.9 million of the year-over-year decline to the removal of enrollees the agency considers improperly or fraudulently signed up, rather than to the premium increase. Both counts describe the same drop in the number of people covered; they differ on how much of it traces to cost pressure versus enrollment-integrity enforcement.
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Why the Enhanced Tax Credits Mattered So Much
The subsidies at the center of the shift were created by the American Rescue Plan Act in 2021 and extended through 2025 by the Inflation Reduction Act. They expanded the standard ACA premium tax credit and, for the first time, capped premium payments as a share of income even for households earning more than four times the federal poverty level, a group that previously received no federal help at all. Those enhanced credits expired December 31, 2025, and marketplace subsidies reverted to the original, less generous ACA formula.
Most marketplace shoppers still receive some help: 87 percent of 2026 enrollees get a premium subsidy, according to the same Peterson-KFF Health System Tracker analysis. But the subsidy most people now get covers less of the bill than it did in 2025, which is why a household can see its monthly payment jump sharply even without switching plans. The Tracker illustrates the scale with a 40-year-old enrollee in Indianapolis earning $65,000 a year: that household’s monthly premium payment was $316 in 2025 with the enhanced credit in place, climbed to $477 in 2026 once the credit expired, and is on track to reach $546 in 2027 if the proposed rate for that plan is approved — a $158 increase in the monthly bill, or 41 percent, over two years.
The increase is sharpest for one specific group: households earning just above four times the federal poverty level, who lost access to any subsidy at all once the enhanced credit expired rather than simply receiving a smaller one. The Health System Tracker describes that group’s cumulative two-year premium increase as especially steep compared with lower-income households that still qualify for some assistance under the standard ACA formula.
A Thinner, Sicker Risk Pool Heading Into 2027
Insurers filing 2027 rates describe a pattern beyond ordinary medical inflation: the people who left marketplace coverage in 2026 tended to be the healthiest ones, since a smaller subsidy is easier to walk away from when someone rarely files a claim. That shift left a pool of remaining enrollees that is, on average, sicker and more expensive to cover than the pool before the enhanced credits expired. Insurers building their 2026 rates estimated that dynamic alone added roughly four percentage points to premiums, and many are penciling in another four-point increase for 2027 as the market keeps adjusting to a smaller, less healthy enrollee base.
That mix-shift effect compounds on top of ordinary cost growth. The underlying cost of medical care and prescription drugs that insurers price into premiums rose an estimated 10 percent for 2027, driven by hospital and physician price increases, growing use of GLP-1 weight-loss and diabetes drugs, and general economic inflation reaching into provider contracts. None of that pressure is unique to marketplace plans, but a risk pool that has already lost its healthiest members has less room to absorb it.
Proposed 2027 Rates, and Why “Proposed” Still Matters
For 2027, insurers across all 50 states and the District of Columbia with public rate filings — 276 companies in total — have proposed a median premium increase of 15 percent, the second consecutive year of double-digit marketplace rate requests. These are proposed figures, not finalized premiums; state insurance regulators still review and can adjust rate filings before they take effect. Last year shows how much that review can move the number: insurers proposed a median 18 percent increase for 2026, and the rate regulators ultimately finalized came in higher, at 20 percent.
If the 2027 proposals hold anywhere near their current level, a household enrolled in a marketplace plan will have seen its insurer’s listed premium climb by more than a third over two years, on top of the separate hit from a smaller subsidy. That two-year comparison — proposed and finalized rates tracked by the Peterson-KFF Health System Tracker — is the number that will land on a monthly statement this fall, regardless of which side of the enrollment-decline debate is right about the cause.
This article was produced with AI assistance and reviewed by a human editor. Figures are linked to their primary sources; where a claim could not be verified from the public record, we say so.
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