ACA health insurance enrollment dropped by 1.4 million. See which states had the biggest swings.

• 1.4 million fewer Americans enrolled in ACA marketplace health insurance in 2026 than a year before.
• Low- and middle-income Americans are facing higher health insurance costs after subsidy loss.
• Experts warn of further ACA enrollment declines as households begin receiving medical bills.

The disappearance of Affordable Care Act subsidies has millions of households feeling health insurance sticker shock.

A report published by the Centers for Medicare & Medicaid found that there are 1.4 million fewer people enrolled in insurance through ACA marketplaces this month compared to January 2025. States like Florida, Ohio, North Carolina, and Georgia saw the most significant dips.

"People have less access to care, and that tends to translate into worse health outcomes," said Matthew Fiedler, a senior fellow at The Brookings Institution. He added that many households' financial security is at risk: "People will face big bills that they either can't pay, and that hurts their credit. Or they do pay, but it requires them to skimp in other areas."

Business Insider broke down the enrollment changes by state — and spoke with experts about why this CMS data doesn't yet tell the whole story of marketplace enrollment in 2026.

Low- and middle-income Americans are seeing a spike in healthcare costs

The number of marketplace enrollees declined most significantly in the South and Southeast, though the majority of states reported a downswing. Florida saw enrollment dive by more than 260,000 people. Registration in a few states, like Texas and California, increased.

People might opt for a marketplace plan if their employer doesn't offer coverage, if they're self-employed, if they lose their job, or if their income is too high to qualify for Medicaid. In context, the 1.4 million dip this year is notable: Marketplace enrollment had jumped from 11 to over 24 million between 2015 and 2025.

The enhanced ACA subsidies — which were passed in 2021 and expired on December 31 — made health insurance more affordable for lower- and middle-income Americans. They allowed people with incomes up to 400% of the poverty line (which is $128,600 annually for a family of four) to claim relief on healthcare costs.

A KFF estimate found that, without these credits in place, Americans in the marketplace could see their out-of-pocket premium costs more than double compared to last year.

White House Spokesperson Kush Desai told Business Insider that "ACA enrollment declined by 3.5 percent between 2025 and 2026 — entirely a result of the Trump administration's commonsense measures to cut waste, fraud, and abuse and remove people who were improperly enrolled on highly-subsidized ACA plans."

Efforts to renew these credits were a point of contention between Democrats and Republicans in Congress, contributing to the latest government shutdown. Lawmakers opted not to renew the subsidies in December, and the latest ACA vote is stalled in the Senate until late January.

Republicans have said they aim to reach a compromise healthcare strategy, but a plan President Donald Trump released on January 15 does not mention subsidies. The plan lays out the administration's goals to lower drug prices and insurance premiums, implement cost-sharing programs, and increase cost transparency.

"The basic contour of the plan is contradictory," said Gideon Lukens, senior fellow and director of research and data analysis at the Center on Budget Policy and Priorities. "Much less the question of how this would work, who would get what, and why this is better than directly covering people's premiums to prevent the spikes millions of people are facing right now."

Analysts expect more people to drop ACA insurance

Policy analysts told Business Insider they expect a steeper decline in ACA enrollment over the next few months. The January report is a snapshot of the marketplace landscape, but comes with caveats.

The latest data shows how many Americans selected a marketplace plan during open enrollment or were automatically renewed for their existing ACA coverage. It doesn't capture how many people have paid their health insurance premiums, meaning that more people are likely to drop coverage once they start receiving bills. A recent Congressional Budget Office report estimates that nearly 4 million Americans will lose or drop insurance over the next decade.

"Many likely signed up when the premiums they would end up facing were uncertain and then waited to see what they would have to pay," said Matthew Buettgens, a senior fellow at The Urban Institute.

For the few states where enrollment spiked, Fielder theorized that local healthcare policy is a factor. California offers its own ACA subsidies, for example, so residents are less vulnerable to the federal changes.

Besides the direct impact on patients, Fielder also said the lapse of ACA credits could put more pressure on hospitals, because providers could see an influx of uninsured patients, and people would be less likely to seek care in the first place.

"There will be facilities that were already financially fragile for whom this is the straw that breaks the camel's back," he said.