Total enrollment in coverage sold through the Affordable Care Act public exchange system could fall by more than 2.6 million over the coming year, to less than 18 million.
KFF has published figures raising that possibility in a summary of results from a survey of 1,117 U.S. adults who had ACA exchange plan coverage in late 2025. The survey was conducted from Feb. 12 through March 2.
KFF found that 69% of 2025 exchange plan users had signed up for ACA exchange plan coverage for 2026, and that 17% of the survey participants who had signed up for 2026 exchange plan coverage were not confident that they could afford to pay their share of the premium bills throughout 2026.
Those figures imply that 15 million of the 22 million people who had ACA exchange plan coverage in late 2025 were in exchange plans in early 2026, but that 2.6 million think they could have trouble paying the premium bills.
About 4%, or 600 million, of the returning exchange plan enrollees said they had not yet made any payments for 2026 exchange plan coverage. Because of a three-month grace period provision, returning enrollees who made all premium payments due in 2025 can keep their coverage in place through March 31, 2026, without making any premium payments in 2026.
Charles Gaba, the editor of ACASignups.net, has estimated that the ACA exchange system had 20.3 million enrollees in mid-February.
Gaba’s estimate and the KFF figures suggest that ACA exchange plan enrollment could fall to 17.7 million.
ACA exchange was created as marketplace for health insurance
The backdrop: Congress created the ACA exchange system to serve as an online supermarket for commercial health insurance.
Consumers can use HealthCare.gov or state-based exchange programs, such as Covered California or Your Health Idaho, to shop for coverage and pay for the coverage with federal premium tax credit premium subsidies.
Analysts at Paragon Health have argued that about 6 million of the 2025 exchange plan enrollees may either have lied about their income, location or other characteristics when they applied for coverage or were the victims of agents or brokers who lied when the producers filled out applications on the enrollees’ behalf.
The administration of President Donald Trump responded to the allegations of enrollment fraud by adopting tough new ACA exchange plan enrollment rules.
Congress added to the ACA exchange program’s enrollment challenges by letting a temporary exchange plan premium subsidy boost adopted during the COVID-19 pandemic expire.
In a February analysis of draft exchange program rules for 2027, analysts at the Centers for Medicare & Medicaid Services, the federal agency that oversees the ACA exchange system, predicted that exchange plans could have about 17.7 million enrollees this year and in 2027.
The KFF and ACASignups.net figures appear to be in line with the CMS forecast.
Traditional employer plan impact: Analysts at the Urban Institute predicted in September 2025 that leaving Trump administration ACA exchange plan enrollment rules in place and failing to extend the COVID-era subsidy boost could lead about 3.2 million extra people to sign up for coverage from employer health plans.
The KFF survey report shows that 5% of the participants who had ACA exchange plan coverage in 2025 are now participating in employer-sponsored health plans.
Another 1% said they had coverage through their parents.
Those figures suggest that about 1.2 million to 1.4 million 2025 exchange plan enrollees may have moved into employer plans as of March 2.
Individual coverage health reimbursement arrangements: One question for employers and benefits advisors is what a sharp decrease in ACA exchange plan enrollment would mean for individual coverage health reimbursement arrangements.
An employee at an employer with an ICHRA plan can use cash from the employer to buy individual or family major medical coverage.
Turmoil in the ACA exchange system could create challenges for ICHRA plans.
One factor that could moderate the impact is that many of the ICHRA vendors have emphasized use of individual and family coverage purchased outside of the ACA exchange system.
Issuers in the off-exchange individual major market use different marketing strategies than issuers on the on-exchange market and have lacked access to ACA exchange premium tax credits. Those differences could buffer the off-exchange plans from some of the pain in the on-exchange market.
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