Following several years of rapid enrollment growth in the Affordable Care Act (ACA) Marketplaces that corresponded with temporary enhanced premium tax credits, enrollment fell for the first time in seven years in 2026, when those tax credits expired. The Assistant Secretary for Planning and Evaluation (ASPE) of the Department of Health and Human Services reported that enrollment declined by nearly three million people between 2025 and 2026.
Earlier federal data and analysis had focused on plan selections, or sign-ups, which decreased by about one million (5%) from last year, but plan selections do not account for enrollees who ultimately do not make their premium payments and are not covered. Effectuated enrollment is different from selection or sign-up data in that it accounts for who paid their premiums. Consumers who canceled their coverage or did not make their premium payments, resulting in termination of coverage, do not contribute to effectuated enrollment totals.
This analysis uses data from the Centers for Medicare and Medicaid Services (CMS) on effectuated enrollment in addition to Open Enrollment plan selections to examine how enrollment in the ACA Marketplaces has changed in 2026.
Key Findings
- Every state except for New Mexico saw a drop in ACA Marketplace enrollment from 2025 to 2026. New Mexico is the only state to fully replace the expired federal enhanced premiums tax credits with state-funded subsidies.
- State-based Marketplaces that run their own enrollment platforms, including those that partially offset the expiring federal enhanced tax credits, generally saw lower drops in enrollment (a 6% decline versus a 15% decline for states that use the federal marketplace).
- The effectuation rate (the rate at which people who initially signed up for a plan kept their coverage by making their premium payments) was lower in 2026 than in recent years.
- States that run their own Marketplaces, and particularly those that offered state-funded subsidies, generally saw higher-than-average effectuation rates.
February effectuated enrollment declined in 2026 to 19.2 million people (as of May 5, 2026), down from 21.8 million people in 2025, a record high enrollment (see note in Methods about 2025 total enrollment). This represents a 12% decline in enrollment year-over-year. Similarly, KFF polling indicated about one in ten 2025 Marketplace enrollees (9%) said they became uninsured for the 2026 plan year. The decline in enrollment coincides with the expiration of the enhanced premium tax credits at the end of 2025.
While effectuated enrollment data do not capture the reasons coverage lapsed, these significant declines in enrollment correspond with rising premium payments after the expiration of enhanced premium tax credits. Without the enhanced credits, premium payments increased substantially for most subsidized enrollees, and some middle-income enrollees who previously qualified for subsidies faced the full cost of coverage for the first time. On average, premium payments net of tax credits increased by 58% for people who signed up for 2026 coverage. A 2026 KFF follow-up survey of people who had been enrolled in ACA Marketplace coverage in 2025 found that eight in 10 enrollees who made changes to their ACA coverage or became uninsured cited cost as a reason, with 17% of returning Marketplace enrollees stating they worried about being able to pay their premiums for the entirety of 2026.
As shown in Figure 2, 2026 was the first year of widespread increases in premium payments. In prior years, including before the implementation of enhanced premium tax credits, people receiving a subsidy were largely sheltered from increases in the premiums charged by insurers. This may at least in part explain why the effectuation rate in 2026 was lower than some years preceding the enhanced premium tax credits. While the drop in enrollment from 2025 to 2026 is the largest drop since the Marketplaces opened, there are still more ACA Marketplace enrollees now than there were before the enhanced premium tax credits were passed.
Effectuated enrollment declined in nearly every state from 2025 to 2026, though the size of the decline varied substantially. New Mexico was the only state to see an increase in effectuated enrollment, growing 14% between 2025 and 2026, coinciding with the state’s premium assistance program that fully replaced the expiring federal enhanced tax credits with state-funded subsidies. Effectuated enrollment in Illinois, Connecticut, Pennsylvania, Idaho, the District of Columbia, Massachusetts, and Texas held relatively flat or fell by less than 5%. Of these states, Texas is the only state that is not a state-based Marketplace. Enrollment in Texas may have been buoyed by a state rule that mandates substantial silver loading, which can lead to more subsidized people being eligible for a bronze plan, or in some cases a gold plan, with little or no premium payment.
At the other end of the spectrum, effectuated enrollment fell by just over 32% in Ohio and Oklahoma, and by more than a quarter in Arizona (30%), South Carolina (29%), Indiana (28%), Michigan (27%), Minnesota (27%), Mississippi (26%), and Louisiana (26%). Of these states, Minnesota is unlike the others in that it offers a Basic Health Program covering low-income people who would otherwise sign up on-exchange. With a relatively higher-income group of Marketplace enrollees, Minnesota enrollees may have been disproportionately affected by the return of the subsidy cliff as enhanced tax credits expired.
A sortable table in the appendix shows the change in enrollment for each state, alongside other information about the type of Marketplace, whether state subsidies are available, and the effectuation rate.
States that run their own enrollment platforms, and particularly those that offered state-funded subsidies, generally saw a smaller drop in enrollment (or an increase, in the case of New Mexico). When weighted by enrollment in each state, those that use theHealthCare.gov platform (and do not offer state-specific subsidies) saw a decline in effectuated enrollment of 15% from 2025 to 2026. However, state-based Marketplaces experienced a 6% decline during the same period. States that offered state-funded subsidies all saw below-average declines in enrollment, or an increase in the case of New Mexico.
Of the 26 states with effectuated enrollment drops smaller than the national average, 18 were state-based Marketplaces, including all nine that offered their own state-funded subsidies. These differences across states suggest that the availability of state-level premium assistance helped cushion the effect of expiring enhanced premium tax credits on enrollees’ ability to maintain coverage, though enrollment changes likely also reflect broader differences in state populations and Marketplace administration.
Changes in both plan selections and effectuated enrollment from 2025 to 2026 varied considerably among states. However, changes in effectuated enrollment were not always well predicted by earlier reported changes in plan selections. In most states (37), both plan selections and effectuated enrollment declined, and the gap between the two widened, meaning that drops in plan selections underpredicted the change in effectuated enrollment. This pattern was particularly pronounced in states such as South Carolina, where plan selections fell 7% but effectuated enrollment fell 29%; Michigan, where plan selections fell 6% but effectuated enrollment fell 27%; and Minnesota, where plan selections fell 8% but effectuated enrollment fell 28%.
For nine states, plan selections rose from 2025 to 2026 but effectuated enrollment fell, reflecting a declining effectuation rate. Louisiana saw the largest divergence: plan selections increased by about 1% but effectuated enrollment fell by 27%. Texas showed the largest difference by number of enrollees: about 206,000 more people signed up this year (a 5% increase in sign-ups), with effectuated enrollment ultimately falling by about 146,000 people (a 4% decrease). Connecticut, Idaho, Massachusetts, Maryland, Pennsylvania, and Rhode Island saw smaller versions of this trend, with modest increases in plan selections alongside slight declines in effectuated enrollment.
Nationwide, the February effectuation rate fell from 90% in 2025 to 83% in 2026. This means a larger share of the people who signed up for coverage during open enrollment did not maintain their coverage, perhaps because they did not pay the first month’s premium, canceled after enrolling, or fell behind on payments and had their coverage terminated. Since 2019, the effectuation rate (measured past the end of the three-month grace period for February premium payment) has been above 90% but was lower in the early years of Marketplace coverage.
This year, Mississippi had the lowest effectuation rate (61%), meaning nearly two in five consumers who signed up during open enrollment did not maintain coverage past January. Similarly, South Carolina, Louisiana, Indiana, and Oklahoma also saw effectuation rates below 70% in 2026. By contrast, New Mexico, California, Nevada, Vermont, and Idaho each had effectuation rates of 95% or more.
States that run their own Marketplaces generally maintained higher effectuation rates than states that use HealthCare.gov. The ten states with the lowest effectuation rates all use the Healthcare.gov platform, while the ten states with the highest effectuation rates are all state-based Marketplaces. These differences may reflect variation in state populations, subsidy structures, or outreach and enrollment assistance efforts. Of state-based Marketplaces, Minnesota and the District of Columbia were the only ones to see lower-than-average effectuation rates. Both markets skew relatively higher-income, as both offer Basic Health Programs that cover lower-income enrollees who would otherwise sign up on exchange.
As with smaller drops in effectuated enrollment, states that implemented state-based subsidy programs to help offset the expiration of the enhanced premium tax credits through their state-based Marketplaces saw higher effectuation rates. Of the nine states offering state-based premium subsidies, seven saw effectuation rates higher than 90%, and all saw effectuation rates higher than the U.S. average. New Mexico, which, as mentioned earlier, fully replaced the lost enhanced premium tax credits through state funds, had the highest effectuation rate among all states at 96%.
These patterns suggest that state policies designed to blunt the effect of rising premiums may be associated with higher rates of enrollees maintaining active coverage, though other factors—such as income levels, Marketplace type, and state outreach efforts—likely also play a role. All states that offered state subsidies to backfill some portion of the expired enhanced premium tax credits were above the median change in effectuated enrollment.
Appendix
Methods
Open enrollment plan selections and monthly effectuated enrollment were collected from Centers for Medicare & Medicaid Services (CMS) sites. Effectuated enrollment in this current analysis refers to enrollees with any coverage in February. For 2025, effectuated enrollment is as of March 15, 2026; for 2026, as of May 5, 2026. Both of these dates are past end of the February premium payment grace period for consumers who had effectuated coverage. State-based subsidy information was obtained from state government websites; see Figure 3 for links to source data. States that operate their own exchanges but use the HealthCare.gov platform are included in the HealthCare.gov category; none of them provide state-funded premium assistance. Weighted average enrollment changes by platform type were calculated using the above described categorizations. Illinois, which switched from using HealthCare.gov in 2025 to its own state-based Marketplace platform in 2026, is counted as a state-based Marketplace for change in effectuated enrollment.
An analysis by ASPE reported the 2025 February effectuated enrollment total to be 22.1 million, but the CMS monthly effectuated enrollment data report a total of 21.8 million enrollees in February 2025. Effectuated enrollment totals may differ across data sources, potentially due to the date of measurement. This KFF analysis is based on CMS monthly effectuated enrollment data (linked above) which indicated a total of 21.8 million effectuated enrollees.
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