ACA Enrollment Declines as Enhanced Subsidies End, Medicaid Work Requirements Begin
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Enrollment in Affordable Care Act (ACA) health plans has dropped by 1.2 million people from last year's record high, following Congress's decision not to extend enhanced subsidies. The decline coincides with Nebraska implementing the first new work requirements for Medicaid expansion enrollees, which could affect thousands. Federal officials note that original subsidies remain in place for most enrollees and attribute part of the enrollment change to efforts to reduce fraud and duplicate coverage.
Facts First
- ACA enrollment for 2026 is 23.1 million, down from a record 24.3 million in 2025.
- Congress did not extend enhanced ACA subsidies, which a consulting firm estimates may lead to enrollment being 17% to 26% lower by 2026.
- Nebraska has imposed new work requirements for Medicaid expansion enrollees, a policy that could affect nearly 30% of that state's expansion population.
- A federal spokesperson stated the enrollment drop is partly due to addressing unauthorized enrollments and identifying people with multiple forms of coverage.
- Original ACA subsidies remain, with 87% of enrollees paying less than $96 a month according to the Health Secretary.
What Happened
Congressional Republicans made changes to the Affordable Care Act (ACA) and Medicaid, including refusing to extend enhanced subsidies. Approximately 1.2 million fewer people are signed up for ACA coverage in 2026 compared to one year ago, bringing enrollment to 23.1 million. Nebraska became the first state to impose new work requirements on Medicaid recipients who enrolled under the ACA expansion. A spokesperson for the Centers for Medicare and Medicaid Services (CMS) stated that 2026 signups were 'only slightly below 2025 levels' and attributed part of the drop to addressing unauthorized or fraudulent enrollments and identifying individuals with multiple forms of coverage.
Why this Matters to You
If you purchase health insurance through the ACA marketplace, your premiums may be higher this year without the enhanced subsidies; the Democratic Congressional Campaign Committee stated that premiums have risen 58% on average. However, Health Secretary Robert F. Kennedy Jr. stated that original ACA subsidies remain in place and that 87% of ACA enrollees pay less than $96 a month. In Nebraska, an estimated 20,000 people on Medicaid expansion could lose their coverage due to the new work requirements, according to the Center on Budget and Policy Priorities. For the broader insurance market, the enrollment decline may lead to changes in plan availability or pricing in future years.
What's Next
Consulting firm Wakely estimates that 2026 enrollment will be 17% to 26% lower than last year, and an insurance industry source reported that some states are already seeing enrollment drops between 20% and 30%. The impact of Nebraska's work requirements will become clearer as the policy is implemented, and other states may consider similar measures. The overall stability of the ACA marketplace may depend on future congressional action regarding subsidies and ongoing federal efforts to manage enrollment integrity.