Five million people who signed up for Affordable Care Act health coverage for 2026 either dropped their plans or failed to pay their premiums, according to a report published Friday by the Department of Health and Human Services.
The number was not entirely a surprise. After initial sign-ups showed 1 million fewer people selected a plan compared to the year before, insurance experts predicted conditions would worsen as people found they could not afford monthly premium payments. Costs doubled on average from 2025 to 2026 after Republican lawmakers allowed enhanced premium tax credits to expire. Democrats shut down the government in October 2025 in an attempt to negotiate an extension of the credits that would have kept prices lower.
According to NPR, Cynthia Cox, director of KFF's Program on the ACA, explained the scope of the drop: "The main takeaway is that enrollment is down 13% from last year. While the Trump administration attributes this drop in enrollment to their attempts to address fraud, this coverage loss happened at the same time millions of people faced double or even triple digit increases in their premium payments with the expiration of enhanced tax credits."
The Trump administration has pointed to fraud as an explanation for the enrollment decline, a theory promoted by the Paragon Health Institute, a conservative think tank with influence in the administration. Many health policy experts are skeptical of that explanation.
Cox noted the relationship between affordability and enrollment is straightforward. "The marketplace doubled in size during the period when there were enhanced subsidies because the coverage was much more affordable and much more appealing to people," she said. "When their costs went up, many of them dropped their coverage."
Stacey Pogue, senior research fellow at the Georgetown Center on Health Insurance Reforms, also rejected the fraud explanation. "I don't see data that point to that conclusion that a 5 million person drop can be explained by allegations of fraud," she said. "There's lots of evidence pointing to people making decisions based" on cost.
Cox acknowledged that fraud exists in ACA marketplaces as it does across insurance markets, but said she does not believe it accounts for the full enrollment decline.
