ACA marketplace enrollment dropped by 1.4m. How will that affect hospitals?

The 2026 health insurance landscape is becoming clearer, and it’s not looking great for patients or providers.

Enrollment in Affordable Care Act (ACA) marketplace plans dropped by 1.4 million, with 22.8 million people covered as of Jan. 3 compared to about 24.2 million this time last year, per data from the Centers for Medicare and Medicaid Services (CMS).

That means there’s still more than twice as many people enrolled in marketplace plans compared to 2020, before the expansion of federal premium tax credits. However, it’s likely even more people will lose coverage in the next few months, thanks to a spike in premiums caused by that expansion’s expiration and other factors like increased hospital costs, per KFF.

The deadline to sign up for ACA coverage was Jan. 15 in most states, but many more people may get kicked off their plans because they can’t afford their increased premiums, JoAnn Volk, codirector of the Center on Health Insurance Reforms at Georgetown University, told Healthcare Brew.

“I think we will see a drop in coverage. We don’t know what that number is yet,” Volk said. “Getting that first premium paid is critical to being enrolled.”

Volk predicts some of those who kept their coverage may have shifted to skimpier plans with cheaper premiums and larger deductibles. Those who left the marketplace altogether may have migrated to alternatives like short-term plans or healthcare sharing ministries that are exempt from ACA regulations. (Volk coauthored a paper in Health Affairs on Jan. 16 that critiques misleading advertising of “junk plans,” which have ramped up marketing in recent months toward people facing sticker shock.)

The increase in underinsured and uninsured patients could negatively impact the whole healthcare system if more patients forgo preventative care to save money and only seek more expensive emergency care, which could increase hospitals’ cost of uncompensated care, Principal Analyst Arielle Trzcinski of Forrester Research told Healthcare Brew.

“It’s going to put pressure on those hospitals and those various practices, on their margins, to the point where they say, ‘We can’t keep our doors open,’ and they need to find a buyer,” Trzcinski said.

Looking beyond the marketplace. Those shopping for Medicare plans also saw their options shrink this year.

Amid high medical costs, many payers tried to reduce enrollment in their Medicare Advantage (MA) plans for 2026 by pulling back their offerings.

“Folks had less choice, less options, and they ended up paying more for potentially less [coverage] than what they had before. There are some exceptions to that, but overall, that was the broader theme,” Trzcinski said.

It’s unclear yet exactly what effect that had, though. MA enrollment counts for January and February aren’t expected until mid-February, per the CMS website. Insurers will likely provide updated enrollment numbers in upcoming earnings calls, too.

The employer coverage landscape for 2026 isn’t clear yet either. Average family premiums rose 6% in 2025, per KFF.

Policy uncertainties. There have been a few new proposed policy fixes to the rising cost of health insurance, but none are in place yet.

Congress continued debating whether to revive the tax credits even after they expired, with the House at one point passing a bill to extend them. But as of Monday evening, that was no longer on the table. A proposed bipartisan spending bill would extend Medicare telehealth coverage and hospital-at-home care, but not the expanded subsidies.

President Donald Trump also unveiled a healthcare plan on Jan. 8. It proposes changes including direct payments to consumers as a replacement for the subsidies that are typically paid to insurers and applied as credits to customers’ bills.

Trzcinski praised the plan’s emphasis on increasing price and data transparency for payers and providers, but noted it lacks enough specificity for an in-depth analysis.

“I would refer to it more as a framework that [Congress] can then use to help inform what legislation looks like,” Trzcinski said.