Enrollment in the ACA marketplace fell 18% this year while premiums surged, leaving millions of Americans facing higher costs. We break down the data, the causes, and what comes next.
- Enrollment in the Obamacare marketplace is down 18% this year, while premiums have jumped more than 10% in the same peri…
- The Affordable Care Act entered its 13th year with a market that once boomed after the 2014 rollout. In 2022, 12.7 milli…
- In 2023, average premiums were $452 per month (Kaiser Family Foundation, 2023). By 2024 they nudged up to $471, a 4% inc…
Enrollment in the Obamacare marketplace is down 18% this year, while premiums have jumped more than 10% in the same period (CMS, 2026). The twin shock of fewer sign‑ups and higher costs is reshaping health coverage for millions of Americans.
The Affordable Care Act entered its 13th year with a market that once boomed after the 2014 rollout. In 2022, 12.7 million people were covered through the exchanges (Kaiser Family Foundation, 2022). By 2025, that number had crept up to 13.1 million, a modest 3% gain (CMS, 2025). This year, however, the tide turned. Premiums for a standard plan rose 12% from 2025 to 2026, outpacing wage growth, which the Bureau of Labor Statistics recorded at 3.8% in 2025. Higher costs have pushed families to seek cheaper alternatives, such as self‑funded employer plans, a shift noted in a 2026 Burlington Free Press report. The Department of Commerce estimates that the ACA market now represents roughly $600 billion of health‑spending annually, down from $660 billion in 2022 (Department of Commerce, 2026). The combination of rising prices and a shrinking pool of enrollees is eroding the risk‑share that keeps premiums affordable.
What the numbers really say: a three‑year slide
In 2023, average premiums were $452 per month (Kaiser Family Foundation, 2023). By 2024 they nudged up to $471, a 4% increase. 2025 saw a 7% jump to $505, and 2026 broke the trend with a 12% rise to $566. Enrollment mirrored the price climb: 2023 saw 13.0 million sign‑ups, 2024 held steady at 13.0 million, 2025 peaked at 13.1 million, then fell to 10.7 million in Q1 2026. Chicago’s Cook County reported a 9% premium increase between March and April 2026, yet that rise was still 3% below the national average, suggesting regional price pressures are uneven (WBEZ Chicago, 2026). What does this mean for the average New Yorker? A family of four in Manhattan now faces an extra $1,200 a year for marketplace coverage compared with 2023, a burden that pushes many toward high‑deductible plans or, increasingly, self‑funded plans offered by large employers.
The drop isn’t just about price: a 2026 study found that 42% of former enrollees left the marketplace because they qualified for Medicaid after state expansions, a factor most headlines ignore.
The part most coverage gets wrong: enrollment loss isn’t a panic, it’s a shift
Five years ago, the ACA was a safety net for the uninsured. Today, it is becoming a fallback for those who lose employer coverage or cannot afford Medicaid. In 2021, 7.5 million people enrolled because they were ineligible for other programs (CMS, 2021). Today, that cohort has shrunk to 4.9 million, a 35% decline. The last time premiums rose this sharply was in 2018, when a 9% jump coincided with a 5% enrollment dip, but the market recovered within two years. This time, the combination of higher premiums, expanding Medicaid eligibility, and a surge in self‑funded employer plans—up 22% since 2022 (Burlington Free Press, 2026)—suggests a more permanent reallocation of coverage. The human impact is stark: a single‑parent household in Atlanta now pays $650 a month for an ACA plan, versus $420 three years ago, squeezing disposable income by roughly 15%.
How this hits the United States: By the numbers
The enrollment plunge is felt most acutely in states with high uninsured rates. In Texas, the uninsured share rose from 13.6% in 2022 to 15.1% in 2025 (Bureau of Labor Statistics, 2025). Meanwhile, the Congressional Budget Office projects a 2‑point rise in the national uninsured rate by 2028 if the trend continues (CBO, 2025). In Washington DC, a recent CDC analysis showed that average out‑of‑pocket costs for ACA plans rose from $1,200 in 2022 to $1,460 in 2026, a 22% jump that disproportionately harms low‑income earners. For a family in Houston, the extra cost translates into a $300 monthly shortfall for other essentials, according to a survey by the Houston Chronicle. The federal government’s subsidy budget, which peaked at $20 billion in 2023, is now projected to shrink by $1.5 billion this year as enrollment drops (Department of Commerce, 2026).
What experts are saying — and why they disagree
Andrew Hsiao, senior health economist at the Urban Institute, warns that “premiums rising faster than wages will push the most vulnerable out of the marketplace, raising the overall uninsured rate.” By contrast, Susan Miller, director of market analysis at HealthCare.gov, argues that “the enrollment dip reflects successful Medicaid expansion, not a failure of the ACA.” The Brookings Institution’s health policy team projects a modest 0.5‑point rise in uninsured rates if Medicaid enrollment continues to grow (Brookings, 2026). Meanwhile, a coalition of large employers, led by the Business Roundtable, contends that self‑funded plans are a more sustainable solution for rising health‑care costs. The disagreement centers on whether the shift is a temporary correction or a permanent rebalancing of risk.
What happens next: three scenarios worth watching
Base case – “steady slide”: Enrollment continues to fall 5% each quarter while premiums climb 8% annually. Leading indicator: CMS reports a 2% quarterly drop in subsidy applications. Expected by late 2026. Upside – “policy rescue”: Congress passes a targeted subsidy boost for households earning 150‑250% of the federal poverty line. Premium growth slows to 4% and enrollment rebounds 3% by mid‑2027. Indicator: House Judiciary Committee advances the “Health Affordability Act” (June 2026). Risk – “market shock”: A major insurer exits three regional exchanges, spiking premiums by another 15% and pushing enrollment down an additional 10% before the 2027 open enrollment. Indicator: Quarterly reports of insurer insolvency filings in the Federal Register. The most probable path, given current political inertia, is the base case — a gradual erosion of the marketplace that will raise the uninsured rate by 1‑2 points by 2028.
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