New state-by-state data show that Affordable Care Act marketplace enrollment fell in every state but New Mexico, with declines of more than a quarter in nine states and a national effectuation rate that fell below 90 percent for the first time since 2019.
The KFF analysis, drawn from Centers for Medicare and Medicaid Services data, puts February effectuated enrollment at 19.2 million people, down from 21.8 million a year earlier — a 12 percent decline and the first drop in seven years. Effectuated enrollment counts only people who actually paid a premium, which makes it a truer measure of who is covered than sign-up figures.
The state-level breakdown is what is new, and it changes the practical meaning of the national number. The decline was not spread evenly. Ohio and Oklahoma each fell just over 32 percent, Arizona 30 percent, South Carolina 29 percent, Indiana 28 percent, and Michigan and Minnesota 27 percent. Mississippi and Louisiana each fell 26 percent. New Mexico was the only state where enrollment rose, growing 14 percent.
The Gap Between Signing Up and Staying Covered
The most consequential figure in the new data is one that rarely makes headlines: the effectuation rate, meaning the share of people who signed up during open enrollment and then kept the coverage by paying premiums.
Nationally, that rate fell from 90 percent to 83 percent. It had held above 90 percent every year since 2019. Mississippi recorded the lowest rate in the country at 61 percent, meaning nearly two in five people who selected a plan did not maintain it past January. South Carolina, Louisiana, Indiana and Oklahoma also fell below 70 percent. At the other end, New Mexico, California, Nevada, Vermont and Idaho each reached 95 percent or higher.
This gap describes a specific household experience. People shopped, chose a plan, and then encountered a January premium bill they could not absorb. In some states the divergence was stark. South Carolina plan selections fell 7 percent while effectuated coverage fell 29 percent. Michigan sign-ups dropped 6 percent while coverage dropped 27 percent. In Louisiana, sign-ups rose about 1 percent while effectuated enrollment fell 27 percent.
The trigger is documented. Enhanced premium tax credits expired at the end of last year and were not extended. Average premium payments net of tax credits rose 58 percent, from about $113 to $178 a month. A KFF follow-up survey found eight in 10 enrollees who changed coverage or became uninsured cited cost, and 17 percent of returning enrollees said they worried about affording premiums for the full year.
Where Coverage Loss Shows Up in a Household First
Losing marketplace coverage rarely announces itself as a crisis. It shows up as a series of small decisions that accumulate.
Prescription costs are usually the first pressure point. Someone managing hypertension, type 2 diabetes, asthma, or a thyroid condition faces full retail pricing at the pharmacy counter. The documented pattern is not stopping medication outright but stretching it: taking a pill every other day, skipping refills, or splitting tablets without clinical guidance. For blood pressure and diabetes drugs, that raises the risk of the exact events the medication prevents.
Preventive screening is the second. Colonoscopies, mammograms, cervical cancer screening, and diabetes screening are covered without cost sharing under ACA plans. Without coverage they become out-of-pocket expenses that are easy to defer for a year, then another. These are the services where delay carries the highest cost, because early detection drives outcomes.
The third pressure point affects people who kept coverage. Many enrollees who stayed did so by switching to cheaper, higher-deductible plans; bronze selection rose 10 percentage points, and average deductibles rose by roughly $1,000 per person. Having insurance and having usable insurance are different things when the deductible must be met before most services are covered.
State Policy Explains Much of the Variation
The reason New Mexico rose while Oklahoma fell by nearly a third is not demographic accident. New Mexico is the only state that fully replaced the expired federal enhanced tax credits with state-funded subsidies. It also recorded the highest effectuation rate in the country, at 96 percent.
The broader pattern holds. States running their own marketplace platforms saw a 6 percent enrollment decline, compared with 15 percent for states using HealthCare.gov. Of the 26 states with smaller-than-average declines, 18 were state-based marketplaces, including all nine that offered their own subsidies. Every state offering state-funded premium assistance saw a below-average decline or, in New Mexico's case, an increase. The 10 states with the lowest effectuation rates all use the federal platform.
Cynthia Cox, senior vice president and director of KFF's program on the ACA, has said survey evidence shows most enrollees who changed plans did so because of cost. HHS attributes a substantial share of the decline to reduced improper enrollment rather than affordability, citing an ASPE report that puts improper enrollments at a peak of 5.6 million, with about 2.6 million remaining after tightened verification. Both factors can contribute. The state pattern, in which retention tracks closely with whether a state added its own subsidies, points toward affordability as the larger driver.
One further note on the numbers: ASPE and CMS report different baselines for the prior year, 22.1 million against 21.8 million. The difference reflects measurement dates, not a dispute about direction.
Options for Households That Have Already Lost Coverage
Anyone unsure whether their coverage is still active should check first. Log in to HealthCare.gov or the relevant state marketplace account and confirm current status. Coverage terminated for nonpayment does not always generate a notice a household notices, and people sometimes discover the lapse at a pharmacy counter.
One rule is worth knowing before making plans around it. A special enrollment period requires involuntary loss of coverage — job loss, aging off a parent's plan, loss of Medicaid or CHIP, a move, marriage or a birth. Nonpayment and voluntary cancellation do not qualify. Households in that position generally must wait for the next open enrollment period, which opens in November, unless a separate qualifying event occurs. Most qualifying events open a 60-day window; loss of Medicaid or CHIP allows 90 days.
Medicaid and CHIP work differently. Enrollment is open year-round, and households whose income dropped should recheck eligibility, because a lower income may now qualify a family in an expansion state. Children may qualify for CHIP even when parents do not qualify for Medicaid.
For prescriptions, manufacturer patient assistance programs exist for most brand-name drugs, and generic substitution is worth discussing with a prescriber before rationing anything. Pharmacy discount cards sometimes beat cash prices, though they do not count toward a deductible. Federally qualified health centers use sliding-scale fees based on income and provide primary care, chronic disease management, and many screenings regardless of insurance status. Nonprofit hospitals are required to maintain financial assistance policies, which are frequently underused.
No one should stop or change a prescribed medication without speaking to a clinician. Telling a prescriber directly that cost is the barrier often produces a workable alternative, because clinicians can switch to generics, adjust to a 90-day supply, or connect patients with assistance programs.
Preliminary insurer filings for next year, covering 77 insurers in 16 states and the District of Columbia, show a median proposed rate increase of 14 percent on top of this year's changes — a second consecutive year of double-digit increases, following a median proposed 18 percent and finalized 20 percent this year. Rates are finalized in late summer. Whether Congress restores the enhanced credits before open enrollment opens will shape how many more people lose or regain coverage.
Frequently Asked Questions
What do the new figures show? KFF analysis of CMS data shows February effectuated ACA marketplace enrollment at 19.2 million, down from 21.8 million the prior year. Every state except New Mexico saw a decline, and the national effectuation rate fell from 90 percent to 83 percent.
Which states lost the most coverage? Ohio and Oklahoma each fell just over 32 percent. Arizona fell 30 percent, South Carolina 29 percent, Indiana 28 percent, Michigan and Minnesota 27 percent each, and Mississippi and Louisiana 26 percent each.
Why did New Mexico gain enrollment? It is the only state that fully replaced the expired federal enhanced premium tax credits with state-funded subsidies. It also recorded the country's highest effectuation rate, at 96 percent.
How much did premiums actually rise? Average premium payments after tax credits rose 58 percent. People with incomes at or above 400 percent of the federal poverty level lost subsidy eligibility entirely and faced full unsubsidized premiums.
What happens to prescriptions after coverage lapses? Medications shift to retail pricing. Rather than rationing doses, patients should tell their prescriber that cost is the barrier, ask about generic alternatives or 90-day supplies, and check manufacturer patient assistance programs.
Can someone get coverage back outside open enrollment? Only with a qualifying event. Coverage terminated for nonpayment or canceled voluntarily does not open a special enrollment period. Medicaid and CHIP enrollment is open year-round, and households whose income fell should recheck eligibility.
Where can uninsured people get care now? Federally qualified health centers offer sliding-scale fees based on income regardless of insurance status. Nonprofit hospitals are required to maintain financial assistance policies, and county health departments provide vaccines and some screenings at reduced cost.
