Where ACA marketplace enrollees stand post-premium tax credits

Nearly 1 in 10 people enrolled in Affordable Care Act (ACA) marketplace plans in 2025 are now uninsured after enhanced tax credits expired at the top of the year, according to survey data from health policy research firm KFF. That amounts to an estimated 2.2 million people.

The tax credits, which made buying health insurance through the ACA marketplace more affordable, were a major sticking point in last year’s record-setting 43-day government shutdown.

More enrollees are expected to lose coverage as the year goes on, Marianne Udow-Phillips, senior advisor at the University of Michigan’s Center for Health and Research Transformation, told Healthcare Brew.

“People can enroll in coverage before they actually have to pay their premiums, so when they actually get the bills to pay, I think we’ll expect to see an even bigger drop,” she said.

By the numbers. In addition to people becoming uninsured, a significant percentage of 2025 enrollees (28%) reported switching to a different marketplace plan, mainly due to cost, according to KFF.

Most survey respondents (80%) said their premiums, deductible, coinsurance, or copays are higher this year compared to 2025.

A lot of people switched to higher-deductible plans with less coverage because the monthly premiums are lower, Udow-Phillips said. That not only leaves people with less coverage, but also increases cost sharing and puts more stress on hospital finances, she added.

Additionally, 49% of enrollees between ages 18 and 29 left the ACA marketplace. That’s worrying, according to Udow-Phillips, because younger people tend to be healthier. If the remaining enrollees in ACA plans are more likely to use more medical services, that could raise premium costs even higher, she explained.

Gerard Anderson, professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health, told Healthcare Brew that sicker people tend to stay in marketplace plans because they often have no better options and can’t jeopardize losing their coverage.

If that cycle of younger, healthier people dropping out while older enrollees needing more medical care remain continues, that could lead to what’s called a “death spiral,” which is when premiums rise and enrollment falls until no one can afford a marketplace plan anymore.

“We’re not there yet,” Anderson said. “But you have to anticipate it. Do I think it’ll happen in 2027? No, but it’s going to happen by 2030, something like that, if it continues this way.”

Going back in time? Without the enhanced tax credits, the healthcare system may start to look more like the pre-ACA days, Udow-Phillips said.

“Before the ACA was put into effect, almost 15% of our population was uninsured,” she said.

A large uninsured population puts financial pressure on hospitals, which are required to treat everybody in the emergency room regardless of insurance status and therefore tend to raise prices in response, she explained

Nadereh Pourat, associate center director at the UCLA Center for Health Policy Research, said a crucial aspect of the ACA was that more people insured equals more stable and affordable healthcare costs.

“Now, we’re going back to the times where fewer people are buying coverage, and people who are buying coverage typically are those that actually know they need it…and then the prices go up,” she said. “It’s a Catch-22, a perfect storm.”