As Affordable Care Act enrollment declines and premiums increase, will Congress take action?

WASHINGTON —

The number of people covered by the Affordable Care Act (ACA) has declined in almost every state compared to last year, according to federal data.

The Trump administration says the drop is due to its crackdown on fraud, but it also comes as many Americans are facing higher monthly payments after Congress allowed some financial assistance to expire earlier this year.

“The exact same policy that I had before went from $800 to $1,200,” said MV Barnes, a 62-year-old retiree, who ultimately decided to drop her coverage altogether.

“My safety net was gone, but I just really didn’t have a choice,” Barnes said. “With my monthly budget, I could not afford that much money.”

Some enrollees are still eligible for financial help from the federal government, but most Republicans and President Donald Trump rejected a push to extend enhanced premium tax credits. The pandemic-era policy temporarily expanded eligibility and the size of the subsidies provided.

Experts say the end of that policy has contributed to increasing out-of-pocket costs for millions of individuals who shop for health insurance through ACA marketplaces.

There are proposals on Capitol Hill to address rising costs, but reform talks have largely fallen out of the headlines in recent months.

What’s driving declining enrollment?

ACA enrollment declined by nearly three million people between 2025 and 2026, a sharp pivot after several years of rapid growth, according to an analysis of federal data.

“We would expect that it actually will continue to decrease throughout the year as more people are feeling the squeeze of the increase in their premium payments,” said Matt McGough, a policy analyst with KFF, a nonprofit health research group.

States like Ohio and Oklahoma were among the hardest hit, losing nearly one-third of enrollees, but the decline was seen in all but one state. New Mexico, the only state in the nation that fully replaced the lost federal subsidies using its own funds, gained roughly 14% more enrollees.

In a June report, the Trump administration attributed a large portion of enrollment growth in prior years to changes that “weakened program integrity safeguards.” The administration claimed that the recent decline was due to its efforts to crack down on fraud and phantom enrollment, when a person is unknowingly enrolled in free plans by brokers or auto-enrolled.

Sen. Bill Cassidy, the Republican chair of the Senate Health, Education, Labor and Pensions Committee, said the data doesn’t reveal the exact causes of the enrollment decline.

“The administration is saying one thing, and there was a lot of that problem with ghost enrollment, but it’s also, I’m sure, that some people dropped off because of increased premiums,” Cassidy said.

Will Washington do anything about it?

In another recent analysis, KFF found that insurers are proposing a second consecutive year of double-digit premium hikes, with insurers citing the rising cost of health services, general economic inflation, and labor shortages as contributing factors.

Democrats want to revive enhanced premium tax credits, but that seems unlikely under the current, Republican-led Congress.

Instead, Sen. Cassidy and President Trump have advocated for annual, direct payments that eligible Americans could put toward their medical expenses.

“Under my plan, this could be up to $2,000 for a family of four. I want the money to go directly to the family, not to be used for a premium,” Cassidy said. “When you use it for a premium, the insurance company takes 20% of it for overhead and profit. When you give it to the family, they will use 100% of it for the care they need.”

It’s not clear yet if that plan can pass by the end of this year as Republicans juggle the president’s other priorities ahead of midterm elections. Cassidy is on his way out after losing his primary to a Trump-backed challenger.

Asked if the president should be putting more pressure on Congress to address rising health care costs, Cassidy said, “I think there should be pressure on everybody in Washington.”