Enrollment in Affordable Care Act marketplace plans fell by more than a million sign-ups for 2026, the sharpest one-year drop since the marketplaces opened, after enhanced premium tax credits expired at the end of 2025 and were not renewed. That figure describes people who picked a plan during open enrollment, not the smaller number who ultimately paid for and kept coverage through the year — a distinction insurers and researchers are watching closely as they plan for 2027. The households that left skew younger and healthier than those who stayed, and that shift is already changing which insurers are willing to remain in the marketplace next year.
Sign-Ups Are Down Over A Million — Actual Coverage Could Fall Much Further
Plan selections during the 2026 Open Enrollment Period fell by more than a million people to 23.1 million, according to a KFF analysis of federal enrollment data first published May 19, 2026 and updated July 15, 2026. But “plan selections” only counts who chose a plan during sign-up season, not who actually paid the first premium and stayed enrolled — a distinction the Centers for Medicare & Medicaid Services draws in its own 2026 Open Enrollment Period national snapshot, which tallies cumulative plan selections state by state and states outright that the release “does not report the number of effectuated enrollments.” CMS has published only that interim plan-selection accounting so far; a final 2026 effectuated-coverage count, the government’s own tracking of who actually paid and kept coverage, has not yet been released.
KFF’s own modeling, built on proprietary January premium-payment data from Wakely Consulting Group, estimates that effectuated enrollment could fall to about 17.5 million people in 2026, and possibly as low as 16.5 million, down from an average of 22.3 million people who had active coverage in 2025. That would be a drop of 3.8 million to 5.8 million people — considerably larger than the sign-up decline alone suggests. This is a modeled projection, not a final government count: CMS has not yet published complete 2026 effectuated-enrollment figures, in part because a grace period let returning enrollees pay premiums as late as March.
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Younger, Healthier Enrollees Left In The Largest Numbers
The households that dropped marketplace coverage were not a random slice of enrollees. Adults ages 18 to 34 accounted for 542,000 of the national decline in plan selections — an 8% drop, from 6.7 million people in 2025 to 6.2 million in 2026 — making up 46% of the entire decline. Consumers earning just above the “subsidy cliff” — between 400% and 500% of the federal poverty line, the income band where the premium tax credit that lowers a marketplace bill stops applying — saw sign-ups fall 44%, a loss of more than 321,000 people, even though that income group made up only 3% of 2025 enrollment.
Both groups tend to be healthier and cheaper to insure than the marketplace population overall, and their departure changes the math for insurers covering everyone who remains. Nine carriers, including Cigna, have announced they will exit some or all of their ACA marketplace states for 2027, while six carriers are entering new states, according to KFF’s insurer-participation tracker as updated September 15, 2026. Cigna, which reported more than 350,000 on-exchange enrollees in early 2026, said the shrinking individual market no longer fits its growth plans.
Going Uninsured Versus Buying Down To A Cheaper Plan
For households that left the marketplace altogether, the consequence is direct: no negotiated marketplace rate and no protection against a costly diagnosis or accident. A KFF follow-up survey of 2025 marketplace enrollees, fielded in late February and early March of 2026, found that 9% said they had become uninsured, and 17% of returning enrollees said they were not confident they could afford their premiums for the full year — a signal that further coverage loss was still working its way through the system months after open enrollment closed.
Households that kept coverage but could not absorb the higher premium mostly took a different route: they bought down to a cheaper metal tier. Under the plan categories HealthCare.gov defines for every marketplace policy, a bronze plan is built to cover 60% of an enrollee’s costs against silver’s 70%, which is why the lower premium comes paired with a higher bill once care is actually needed. The share of marketplace consumers choosing bronze plans rose from 30% (7.3 million people) in 2025 to 40% (9.2 million) in 2026, while silver-plan selections fell to a record-low 43% share, down from 57% the year before. That shift carries its own cost. The average marketplace deductible jumped 37%, or $1,027 per person, to a record $3,786 in 2026 — the steepest single-year deductible increase since the marketplaces launched in 2014, driven largely by the move into higher-deductible bronze coverage.
The tradeoff between the two paths is concrete. A household that bought down to bronze coverage keeps a lower monthly bill and stays protected against a catastrophic bill, but now clears thousands more in routine costs before that protection engages. A household that went uninsured avoids the premium and the deductible both, until a bill arrives with no negotiated rate behind it and no insurer covering any share. KFF’s insurer-participation tracker, last updated September 15, 2026, is the clearest sign yet of where that split is heading: as healthier, better-off enrollees move toward one path or the other, the marketplace that remains is smaller, and more insurers are concluding it costs more to serve.
The Same Cost Math Follows Households Into Medicare
Households working through higher marketplace premiums and deductibles today face a similar problem years down the road once they age into Medicare, where premium surcharges and drug costs shift from year to year with little advance notice. Medicare carries its own forms, appeal windows and coverage rules that arrive without a plain guide attached, and a missed one can be as costly as a bronze-plan deductible. Tracking which rule applies and when protects a retirement budget the same way tracking a marketplace deductible protects a working one.
The Medicare Cost & Coverage Protection Kit arranges the new Part D out-of-pocket cap alongside the prior-authorization appeal steps, plus a medication and cost tracker for logging expenses across the year.
Compare a plan’s own limits against the new Part D out-of-pocket cap in The Medicare Cost & Coverage Protection Kit.
AI-assisted research and drafting; reviewed by an editor.
