Millions of Americans lost their Affordable Care Act health insurance coverage over the past year, according to newly released federal data that offers the first complete state-by-state look at how dramatically enrollment has fallen since enhanced subsidies expired at the start of this year.
The data, which the Trump administration posted in late June and was first reported on by The Associated Press, shows that approximately 2.6 million fewer people held ACA marketplace plans in February compared with the same month a year earlier.
The figures capture not just how many people signed up for or were automatically re-enrolled in plans for 2026, but also how many actually paid their first month’s premium to keep that coverage active. According to Cynthia Cox, a vice president and director of the ACA program at the healthcare research nonprofit KFF — who reviewed the dataset — the numbers also account for people who were removed from coverage after failing to pay during a grace period.
“This is the first time we’ve seen state-level data that shows how much ACA marketplace enrollment truly fell,” Cox said. “It’s in line with our expectations, but it does show a very steep drop in the number of people with ACA coverage.”
Health policy analysts have been closely watching ACA enrollment figures since the so-called enhanced premium tax credits expired, causing monthly health insurance costs for many Americans to double or even triple. That pricing shock pushed some people to drop coverage altogether. The subsidies had been the focus of an intense battle in Congress last fall, with Democrats and a number of Republicans urging renewal.
The rising cost of health insurance — across ACA plans and other programs — has become a significant issue as voters head toward November elections, with affordability ranking among their top concerns.
Last week, the U.S. Department of Health and Human Services released a report suggesting the enrollment decline could largely be explained by a federal crackdown on fraudulent or so-called “phantom” enrollments. However, health analysts have pushed back on that explanation, saying the drop is more likely tied to the January 1st expiration of federal subsidies and other policy changes, including stricter rules about which immigrants can access subsidized coverage.
An AP analysis of the data found that Ohio and Oklahoma each experienced enrollment declines of more than 32% — the largest proportional losses of any state in the country.
Several other states were close behind, each losing more than a quarter of their ACA-enrolled populations: Arizona, South Carolina, Minnesota, Indiana, Michigan, Mississippi, Louisiana, and Missouri.
Florida, which relies heavily on ACA coverage partly because it did not expand Medicaid and has a large population of gig workers and self-employed residents, still leads all states with nearly 4 million marketplace enrollees. However, it also recorded the highest raw number of people losing coverage — around 443,000 — of any state this year.
The data does not reveal whether those who dropped ACA coverage found insurance elsewhere. While some may have obtained coverage through an employer or other source, Cox said most people who leave the ACA marketplace likely go without any insurance at all, since the marketplace tends to be a “place of last resort” for those who have no other options.
Several of the states hit hardest by this year’s enrollment drops were the same ones that saw the biggest gains when enhanced subsidies were first introduced during the COVID-19 pandemic. Cox said that pattern makes sense, since those states likely had large numbers of people who only enrolled because the enhanced subsidies made coverage affordable enough to consider.
Just one state bucked the national trend: New Mexico saw its ACA enrollment grow by roughly 14% compared with last year. It is the only state in the country that fully replaced the expired federal subsidies using its own state money.
Nationwide, about three out of five states use the federal marketplace HealthCare.gov, while the remaining states run their own ACA marketplaces. The new data shows that states relying on the federal marketplace lost larger shares of enrollees than those operating their own exchanges.
One likely reason is that many states with their own marketplaces took steps to cushion the blow for residents when the enhanced subsidies expired in January. New Mexico is the most dramatic example: during a special legislative session last fall, state lawmakers approved a plan to use state funds to replace the missing federal subsidies through mid-2026. In March, the state’s governor signed legislation extending that financial backstop through mid-2027.
