Costs, Coverage, and Enrollment Changes: Exploring Current Public Opinion and Policy on the ACA Marketplaces
Following the expiration of the enhanced premium tax credits at the end of 2025, many people enrolled in the ACA Marketplaces have faced higher health care costs and reconsidered their coverage options amid affordability concerns, as shown in KFF’s new follow-up survey. Eight in 10 say their health care costs are up, including half who say they are a lot higher. Among returning ACA enrollees, one in six say they are not confident they will be able to afford their premium for the entire year, and a majority expect to cut back on basic household expenses. In addition, KFF found that one in 10 enrollees dropped their Marketplace coverage and are now uninsured, and about three in 10 switched ACA plans.
On March 26, 2026, KFF held a virtual event focused on the costs, coverage, and enrollment trends in the ACA Marketplaces, discussing current views of Marketplace enrollees based on our follow-up survey and reviewing recent policy developments. KFF’s President and CEO, Dr. Drew Altman, framed the conversation, offering perspective on how these changes, as well as broader health care affordability challenges, are driving health care costs to the top of voters’ minds. Larry Levitt, executive vice president for health policy, moderated the discussion with two of KFF’s experts: Cynthia Cox, senior vice president and director of KFF’s ACA program, and Lunna Lopes, senior survey manager.
Welcome & Framing Remarks
Moderator & Presenters
Cynthia Cox
Senior Vice President, Director, Program on the ACA, Director, Peterson-KFF Health System Tracker Project
In his opening remarks, Dr. Altman explained that, while coverage loss and shifts to high-deductible health plans were anticipated, the survey data indicated that the largest affected group consisted of enrollees paying more to maintain coverage and subsequently reducing spending on other basic needs.
“For me, the surprise in the survey was that, in terms of just the raw numbers of people who are affected, the biggest impact was actually on those who are paying more to keep their coverage because they feel they need it. It reflects how much people value health insurance coverage, that they have to skimp on everything else in their lives…”
Drew Altman, KFF President and CEO
Dr. Alman also noted that other KFF polling shows healthcare costs rising to the top of voters’ economic concerns, ahead of food, utilities, housing, and gas.
Cynthia Cox provided context via the policy landscape, noting that ACA Marketplace enrollees are estimated to have faced an average 114% increase in premium payments for 2026 to remain in the same plan. She explained that available administrative data are currently limited; sign-up and automatic re-enrollment figures suggest that approximately 23 million people have ACA Marketplace plans for 2026, roughly one million fewer than the prior year. However, “effectuated” enrollment data, which shows how many ACA Marketplace enrollees paid for their plans, will not begin to be available until this summer. Cox also noted that enrollees with incomes above four times the federal poverty level saw a “double whammy” in cost increases, facing both the loss of the subsidy and an increase in in insurer-charged premiums, which increased on average by about 20% or more.
Lunna Lopes presented results from KFF’s follow-up survey of Marketplace enrollees, in which more than 1,100 of the same individuals interviewed in November 2025 were re-interviewed in late February 2026. Among returning Marketplace enrollees, eight in 10 reported higher healthcare costs compared to the prior year, and approximately one in 10 of all 2025 Marketplace enrollees are now uninsured, with cost cited as the primary reason. A majority of returning enrollees reported cutting back on food and basic household expenses to cover healthcare costs, a figure that rose to nearly two-thirds among those with chronic health conditions. Approximately one-quarter of those who switched Marketplace plans moved to a lower metal tier, which may have reduced monthly premiums but increased deductibles and copays.
During the Q&A session, Cox and Lopes addressed the following topics:
- Deductibles and the trade-offs of switching metal tiers (e.g., silver to bronze)
- Partisan makeup of ACA Marketplace enrollees
- Impact on enrollees with chronic health conditions and younger enrollees
- The grace period for enrollees who were automatically re-enrolled but have not yet paid a premium
- Medical debt among marketplace enrollees
- State-level strategies to offset the subsidy expiration
- Changes in the reconciliation package (One Big Beautiful Bill Act), including the end of automatic re-enrollment and the removal of repayment limits on premium tax credit reconciliation
- Proposed Trump Administration regulatory changes, including multi-year catastrophic plans with very high deductibles and non-network (reference pricing) plan structures
- Likelihood of Congress extending the enhanced premium subsidies this year
AI Usage Disclosure: This event summary was created with assistance from AI tools. It was reviewed and edited by KFF Staff.