When making the appointment, Zordani said, he’d been told the clinic was in his insurer’s network. Upon arrival, Zordani was summoned to the clinic’s financial office and told he had to make a $5,000 preservice deposit, because Mayo had since determined it did not accept his insurance. He was automatically designated “self-pay,” even though his plan had out-of-network benefits.

Not having that kind of cash on hand — and angry on principle — he refused. His appointment was canceled.

“I was so livid,” Zordani said, recalling that day in early April 2024. He later learned that Mayo had sent a message to him in his insurance carrier’s patient portal shortly before his visit with an estimate of the cost: $565, not the larger amount it later demanded.

Traditionally, patients usually receive bills for their share only after getting treatment. But what Zordani faced is becoming increasingly common — hospitals or other medical providers seeking prepayments.

“We regret that this individual’s experience did not meet the high standard of communication we strive to provide when helping our patients understand their insurance coverage and financial responsibility,” Andrea Kalmanovitz, Mayo’s communications director, said in an emailed statement. “When prospective patients don’t have clarity that Mayo Clinic is not in-network with their health plan, unexpected pre-service deposit requests may result.”

says it requires prepayments in a variety of cases, including for “noncontracted” — also known as out-of-network — insurance plans.

The trend of hospitals asking for money up front represents a double whammy for patients.

Medical providers are collecting larger shares of what patients might owe at a time when rising deductibles mean patients are owing more for care. The preservice charge could be all or part of a remaining deductible, for example, or a sizable percentage of what the visit or treatment might cost. Those deductibles go up when hospital prices, drug costs, and labor expenses increase, as insurers try to slow premium growth by shifting more costs to patients.

People are “basically being asked to self-insure,” said Richard Gundling, a senior vice president at the Healthcare Financial Management Association, an organization for finance professionals.

As that happens, hospitals figure more patients will have trouble meeting those deductibles, so they want to get as much up front as possible.

“Things like preservice deposits and those kinds of moves are probably going to become more and more likely,” said Chip Kahn, a visiting senior fellow at KFF and the American Enterprise Institute and former president and CEO of the Federation of American Hospitals. “That will make it harder on the provider, the clinician, and harder on the patients.”

The deposits can’t be viewed in isolation, Gundling said: It’s a bigger issue than just hospitals asking for money up front. The challenge, he said, is: “How do we maintain access to care when more patients can’t absorb the level of out-of-pocket costs?”

Already, consumers are increasingly worried about paying for healthcare. A recent found that lower out-of-pocket costs ranked as the top change insured adults would like to see from their coverage plans. KFF is a health information nonprofit that includes ³Ô¹Ï²»´òìÈ.

The average deductible in family coverage offered by employers is $3,762 per person, , while the average deductible in Affordable Care Act plans to a similar amount, $3,786.

A Consumer Concern

, a health insurance consumer assistance program in New York state, hears from people who are concerned about prepayments, said Diane Spicer, a supervising attorney.

“We see this mostly with insured folks who are seeking out-of-network care but who have out-of-network coverage,” Spicer said, “and also sometimes for care that is not covered.”

Just how many hospitals collect what are often called point-of-service payments is not known, according to Kodiak Solutions, a technology company that provides services to health systems to help manage their revenue.

“But it is becoming more and more the center of many of our conversations with health systems,” said , a vice president leading Kodiak’s revenue cycle intelligence team.

In addition to Mayo, Baltimore-based says that “it is our policy to collect all amounts owed before services are rendered” for non-emergency care. University of Texas-affiliated in Houston, one of the nation’s premier cancer treatment centers, says patients who pay for their own care “will be asked to pay an initial deposit determined by the care center, based on the type of cancer.”

On average, hospitals collect about a quarter of what they expect the patient will owe, Szaflarski said, based on what they estimate the insurer will pay — a percentage that has grown in recent years.

For example, if a person is coming in for imaging and the insurer will reimburse $1,000 for that scan, the hospital will seek $250 from the patient up front, he said. “That used to be closer to $150.”

It also varies by hospital, and sometimes by state.

“The state of Indiana has some of the lowest cash collections in the country. They are Midwest nice,” Szaflarski said. He added that California and Texas are among those that collect more.

Even as hospitals increasingly collect more upfront payments, however, their uncollected debt is also rising, according to data Kodiak collected from more than 2,300 hospitals nationwide.

said that’s because of a “fundamental shift” in coverage as plans “increasingly feature higher deductibles, greater coinsurance, and more complex cost-sharing structures: all elements that increase the nominal patient responsibility without improving—and often reducing—the probability of collection.”

While many hospitals are doing fine, some, especially in rural areas, have thin margins — and things could soon tighten further as cuts to ACA and Medicaid funding lead to more people being uninsured.

As a result, hospitals “have to be concerned” about every cost-sharing dollar, Kahn said.

After Zordani returned to Denver, he said, it took a while to find another specialist. He eventually had a procedure in late June 2024, at a Denver hospital not affiliated with Mayo, to fix a .

The following fall, he filed a in Arizona civil court. He was awarded $47,500 in economic damages and attorney fees after an arbitrator in September 2025 determined Mayo violated a state consumer fraud law because it failed to reach him to say that his plan was not in-network before he traveled. Mayo’s statement to ³Ô¹Ï²»´òìÈ did not include any reference to the settlement.

“Had they notified me in timely fashion as required, I would not have flown there,” Zordani said. He’s still angry that the clinic didn’t ask his permission before designating his care as self-pay, which meant he wasn’t going to use his insurance, and he’s still unclear on how they calculated the $5,000 preservice amount.

When Do Consumers Have to Make Preservice Payments?

There is one clear rule: In emergency situations, hospitals that accept federal Medicare financing cannot, , demand upfront payment before stabilizing a patient who arrives at an ER, said , a senior fellow and health policy researcher at the Brookings Institution.

Other consumer protections are less clear.

Patients who get in-network care may have some recourse in their contracts with their insurers, so they should check the fine print, experts told ³Ô¹Ï²»´òìÈ.

“In out-of-network settings, I’m not aware of any barriers that would prevent a provider from doing this,” Fiedler said of preservice deposits.

How those amounts are calculated also appears widely up to the provider and can be opaque.

“They could just say $1,500 and you’d be like, ‘Oh, is that 10%, or is that how much is left on my deductible?’” said , senior director of healthcare campaigns at PIRG, a national federation of independent consumer advocacy groups.

Yet, she added, the patient might be scheduling three months in advance, so the provider wouldn’t know how much was left on the deductible. She recommends consumers ask for an itemized bill and call their insurer to find out whether it has rules regarding the charges.

Also unclear are how and when patients get their money back if they overpay.

Overpayments can happen if patients don’t require the services originally estimated or when insurers pay other bills first, such as the anesthesiology cost or a surgeon’s fees. If those payments are counted toward a patient’s deductible, yet the patient had already made a prepayment to the hospital for the expected deductible, to the hospital.

How soon they get their money back can vary and can depend on state laws, though a small number of states directly address the issue. As of this year, medical providers to reimburse patients within 30 days of a determination of an overpayment. Some states, including Maryland, prohibit certain hospitals from requiring prepayment simply to avoid offering financial assistance.

After alleging that some patients had to wait more than a year to get reimbursed, Arizona Attorney General Kris Mayes recently under state consumer protection laws against SimonMed Imaging, which has 170 locations in 10 states.

, SimonMed agreed to issue refunds within an average of 60 days.

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Enrollment in Affordable Care Act plans fell by nearly 3 million this year to about 19.2 million, following steep premium increases by insurers and the Republican-led Congress’ unwillingness to extend more generous premium subsidies. On average, ACA customers in premium payments this year, a 58% increase from 2025, according to KFF, while their deductibles — the amount consumers must pay annually before insurers pick up their share — have climbed 37% to nearly $3,800 a year.

“These are real people who are now forced to make impossible choices,” said Annalyse Keller, a spokesperson for a large coalition of lobby organizations for the healthcare industry, including insurers and patient advocacy groups.

But a released in June, written mostly by President Donald Trump’s political appointees and allies, asserts that 5.6 million people were fraudulently enrolled in ACA plans in 2025, and that the Trump administration removed 2.9 million of them — the same number as the 2026 drop in enrollment.

There’s little dispute that the ACA suffers from some fraud, as do most government programs. The administration said it has taken actions to tighten the enrollment process to thwart brokers who fraudulently enroll people without their knowledge.

For example, the administration in August 2025 halted a Biden-era initiative that allowed low-income people to sign up for coverage year-round. Regulators 1.5 million people since 2025 for reasons such as not meeting a requirement to file their taxes over two years or being concurrently enrolled in another health program, such as Medicaid, which is not allowed.

But health policy experts say that the administration is overstating the extent of ACA fraud and that the HHS report relies on debatable assumptions, such as that all sign-ups under the year-round enrollment program for low-income people were potentially fraudulent. ACA enrollment fell off a cliff because of escalating prices for insurance plans, policy analysts say, which the administration’s done nothing to stem.

“The top-level claim” that all the decline in enrollment since 2025 is because of improper or fraudulent enrollees leaving the market “is not remotely credible,” said , a senior fellow at the Brookings Institution. “We know that lots of people have seen higher premiums, and there’s really good evidence that when premiums go up, people drop coverage.”

Healthcare costs are a big concern for voters ahead of November’s midterm elections, and both Democrats and Republicans are trying to spin the issue to their advantage. Democrats argue more needs to be done to make insurance less expensive for consumers, while Republicans are trying to focus on the need to save taxpayer dollars from fraud.

found that voters trust Democrats over Republicans to address healthcare costs (37% vs. 26%). The poll also found, though, that 55% of Republican voters consider it extremely important for candidates to address healthcare fraud, more than any other issue, showing that the White House’s effort to shift focus from costs has had some success with its own supporters.

But Jonathan Oberlander, a professor of health policy and management at the University of North Carolina, questioned whether the fraud narrative will hold up as voters continue to struggle with rising costs.

“It will be cold comfort to the very real persons who could no longer afford coverage and dropped their plans,” he said in an email to ³Ô¹Ï²»´òìÈ.

How We Got Here

Under President Joe Biden, Congress that included more generous tax subsidies for people enrolled in Obamacare, starting in 2021. Those enhanced subsidies lowered premium payments, for a large enough tax credit to reduce their monthly payment to zero. The Biden-era law also allowed wealthier households to get assistance.

ACA coverage essentially doubled, from just over 11 million Americans in 2021 to more than 22 million in 2025, according to the HHS report.

Republicans and conservative groups argue that the growth wasn’t driven only by people newly enrolling because of lower premiums. Instead, they say, the enhanced subsidies, along with other Biden-era policies — including easing income verification requirements for some enrollees — invited fraud. Unscrupulous, commission-seeking insurance brokers found it easier to sign people up for coverage, often without their knowledge, while ordinary consumers could more easily fudge their income and qualify for the largest subsidy possible.

The conservative Paragon Health Institute’s president, Brian Blase, wrote that the HHS report’s conclusion on the scope of improper enrollment is likely an undercount. He remains unconvinced by the arguments that rising premiums are to blame for the sharp drop in ACA enrollment, saying subsidies remain generous for many people.

The Administration’s Current Targets

The debate will continue as more enrollment data emerges from the federal marketplace and the exchanges run by states. Some policy experts — including the consulting group Wakely — expect the year to end with the number of ACA policyholders down by .

Trump’s regulators will likely connect further drops with anti-fraud efforts. The HHS report alleges there are potentially millions more who remain improperly enrolled. The report’s authors noted that some of the administration’s anti-fraud proposals have been blocked by court rulings.

HHS released June 27, HHS Secretary Robert F. Kennedy Jr. pats Mehmet Oz, the head of the Centers for Medicare & Medicaid Services, on the back for the number of canceled ACA plans so far. Oz threatens potential ACA hucksters: “Don’t walk away from us, run! Because we are going to find you.”

In an email responding to ³Ô¹Ï²»´òìÈ’ questions, CMS spokesperson Christopher Krepich said his agency this summer will block ACA applications made by brokers that lack a Social Security number. By open enrollment this fall, CMS plans to require more identify-proofing when brokers enroll people and will limit a broker’s access to accounts until that person “has been authorized by the consumer to work on their behalf.”

How some suspicious enrollments will be removed is spelled out in emails sent in June to insurance carriers and obtained by ³Ô¹Ï²»´òìÈ.

CMS told insurers that the agency will send them files for ACA accounts it believes are potentially unauthorized. Each flagged consumer account will have used a sales broker to enroll, be in a zero-premium plan, and lack a Social Security or an immigration documentation number — which Kennedy said in the video is a glaring sign of fraud.

Insurers must try to contact the enrollees to verify that they signed up for coverage. After 60 days, insurers must report policies they were unable to verify to CMS, which will cancel them.

Krepich wrote that carriers are cooperating with efforts to investigate accounts with missing or unverified information.

Policy experts, including Fiedler, note that the absence of a Social Security number doesn’t automatically prove fraud. While it could indicate a fake enrollee, a missing Social Security number might also be a simple oversight by the consumer or their broker, for example, or a newborn added to a parent’s account at birth, before they’ve received a number.

“That the administration put it in a report and did not summarily terminate these enrollments suggests they believe there is some mix of different circumstances,” Fiedler said.

The administration report singles out another segment of enrollments as suspicious: very low-income, subsidy-eligible people who shifted to plans that carry no monthly premium, suggesting “fraudulent agents and brokers are moving them to keep gaining commissions and avoid detection.” The report also cites ACA enrollees who file no medical claims as suspicious.

Policy experts question the assumptions behind those concerns.

Younger or lower-income people use healthcare less often, for example, which can explain why they may make no claims — particularly when they must first spend thousands of dollars out-of-pocket to meet high deductibles.

And very low-income people may switch to plans with higher deductibles in exchange for making no premium payment because they struggle to come up with the $50 or $80 monthly share that other plans might require.

“People are hurting for money,” said Florida insurance agent Jason Fine. “I literally have people who can’t afford to pay $15. I would not immediately assume that a person who went from a silver plan to a bronze plan, that it’s fraud,” referring to two types of ACA plans.

Fine said the administration needs to focus on better enforcement of existing rules, saying he has reported to regulators dozens of unscrupulous agents who have switched clients without authorization, yet none were barred from selling ACA policies.

He and other agents continue to push for adding multifactor identification, as banks and other financial institutions use, to the federal ACA marketplace. Some states that run their own exchanges have two-factor authentication or other types of ID verification and have not reported problems with unauthorized switching.

CMS — under both Biden and Trump — has not added two-factor authentication to the federal marketplace, healthcare.gov.

Rep. Glenn Grothman (R-Wis.) to require it in June, but its prospects are murky.

“It will help reduce fraud,” said Ronnell Nolan, who leads Health Agents for America, a lobbying group that has long urged CMS to add the feature. Grothman’s legislation, she said, might “encourage CMS to do it themselves.”

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Even the bill’s backers say securing passage this year is a long shot. But the effort is one more opportunity for Democrats to highlight voters’ frustration about healthcare costs leading into the November election.

Polls show Americans are very concerned about affordability, with finding fewer than half of Americans say they can consistently afford healthcare.

Wyden’s bill would focus on what many consider a critical pocketbook issue in traditional Medicare: There’s no limit on what a beneficiary could pay in cost sharing.

“Everyone else in the health insurance neighborhood has one — employer coverage, the Affordable Care Act, all of them have a cap,” the Oregon Democrat told ³Ô¹Ï²»´òìÈ. “There’s no good, common-sense reason why the flagship health program doesn’t have the same protection.”

Critics of a cap, meanwhile, are likely to pounce on the cost to the federal budget, which could be significant.

Wyden, already making the battle lines clear, added, “I suspect it will come up on the floor of the Senate that Democrats want to give a fair shake to people on traditional Medicare and Republicans want to help billionaires.”

Policy, Political Dynamics at Work

The underlying issue is the 20% share of have to pay for medical services after they’ve met any deductibles. Without a ceiling or upper limit, an expensive condition such as cancer or a long hospital stay could result in beneficiaries paying thousands of dollars in costs.

That concern leads enrolled in traditional Medicare to purchase separate insurance, often called Medigap. (Others get such coverage through job-based retiree plans.)

Medigap insurance plans have seen rapid premium increases and can cost thousands of dollars a year, especially for couples. That price tag can be unaffordable for some beneficiaries, who may instead turn to private-sector Medicare Advantage plans offered by commercial insurers, or go without.

The Wyden proposal would set a $5,000 cap in traditional Medicare. Any amounts paid by a Medigap plan or a retiree health plan toward beneficiaries’ care would count toward that cap. It also includes other provisions to help older people with lower incomes, including eliminating an asset test to qualify for special programs that help reduce costs.

Medicare would pick up any amounts over that $5,000 limit, which is lower than the one Congress set for the rival Advantage plans — , although insurers can set smaller amounts.

Setting a cap in the traditional program, proponents argue, would help level the playing field between traditional Medicare and Advantage plans, which often cost consumers far less than traditional Medicare with a Medigap supplement. Premiums for these policies would probably be lower, they say, because the insurers’ financial exposure would be limited.

The Medicare Advantage program has historically had strong support from Republicans, who like its private-sector aspect and note that it can potentially do more to control costs, such as by using specific networks of doctors and hospitals, or requiring preapproval for some services, which the traditional program cannot do.

The plans also offer enrollees additional benefits, such as eyeglasses, hearing aids, and prescription drug coverage, and have now attracted more than .

Along with that growth, however, has also come increased scrutiny over concerns about denials of patient services and the to the traditional program. Recently, some health systems have , citing concerns about tardy payments or prior authorization requirements, while insurers where they offer Advantage coverage.

The bill has not yet been analyzed by the Congressional Budget Office, so there is no official estimate of increased costs to taxpayers for Medicare. Still, it would raise those costs — at a time when other health programs are being cut, the Medicare trust fund is scheduled to of funding in 2033, and the .

That is likely to draw sharp rebukes from fiscal hawks and other conservatives who question whether billions in tax dollars should be used to pick up costs that would otherwise be paid by enrollees or by the supplemental insurance plans many purchase to do so. They are likely to note that beneficiaries could also choose to join private sector Advantage plans, which eliminate the need for supplementary insurance coverage such as Medigap.

Key Questions: Who Benefits? Who Pays?

A cap’s cost to taxpayers, while not officially scored yet, is likely to be significant, although adding one could also save individual consumers money. A recent study from Brown University gives some clues.

A $5,000 cap could save enrollees , the study says, both in direct savings and reductions in their Medigap supplemental premiums. Just over 11% of traditional Medicare beneficiaries, about 3.2 million, would directly benefit from such a cap if it was implemented in 2028, said the study, which did not receive outside funding.

Over the next 10 years, it estimates, just over 52% of all traditional beneficiaries would exceed the $5,000 cap at least once.

Still, lead author Andrew Ryan, a professor at Brown’s School of Public Health, said analysts estimated such a cap “could cost over $50 billion annually, which is a lot of money” to add to the federal balance sheet.

Critics are likely to focus on the cap’s expense and the number of people who might benefit.

“How many people are hitting a level of cost they can’t afford on Medicare? “asked Jackson Hammond, a senior policy analyst with the Paragon Health Institute, a conservative think tank influential with the GOP.

Any cap “is generally going to increase expenses for the program without adding a lot of benefits to enrollees,” said Hammond, who spoke with ³Ô¹Ï²»´òìÈ before the legislation was introduced.

Supporters, though, have a different view.

Certainly, with “any policy that’s going to cost money, there will be an argument over where the money is coming from,” said Brian Keyser, a research associate at the liberal Center for American Progress who also spoke with ³Ô¹Ï²»´òìÈ before the Wyden measure was introduced.

Keyser co-authored that suggested lawmakers could pay for changes in traditional Medicare, such as an out-of-pocket cap, if they reduced the amount the government pays Medicare Advantage insurers, pointing to government estimates that Advantage would cost the government $76 billion more this year than if the same number of people were in the traditional program.

Finding a way to add a cap “is right and fair because without it, people who become seriously ill can spend their life savings on cost-sharing Medicare,” Keyser said.

Such an idea, however, on and off for years. Knowing that, the bill’s backers acknowledge that passage is unlikely — but they say they’re playing the long game for now.

“We’re going to push for it in the next Congress, when we believe we will be in the majority,” Wyden said.

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The measure is unlikely to pass in the Republican-controlled Congress, but Democrats could use the vote against their opponents on the campaign trail.

When the ACA rule was released in May, the Trump administration as a means to combat enrollment fraud, lower premiums for some people, and offer a wider range of insurance plans, including ones with no set network of doctors or hospitals.

But many Democrats warned the changes would hurt consumers already suffering from high healthcare costs as well as higher prices for gas, groceries, and other household needs. Estimates from the administration found the regulation, called a notice of benefit and payment parameters, could cause to lose ACA coverage.

Senate Minority Leader Chuck Schumer and fellow Democratic Sens. Tammy Baldwin of Wisconsin and Ron Wyden of Oregon plan to introduce on Wednesday a to block the rule.

Baldwin told ³Ô¹Ï²»´òìÈ in a statement that the rule is “misguided” and said she was “committed to doing everything she can” to stop Republicans from “kicking Americans off their health care.”

The directive from the Centers for Medicare & Medicaid Services is an annual exercise that sets standards for ACA coverage during the coming year. Some of the changes in the finalized 2027 rule are technical, but many would affect consumers directly.

They include tighter income verification requirements. The rule also stipulates more eligibility checks on people applying outside of the normal annual enrollment period for such reasons as marriage, divorce, or loss of job-based coverage.

ACA plans themselves would look different too. Insurers would be able to offer some plans with 30% higher out-of-pocket limits (the amount consumers may have to pay each year in cost sharing such as copayments and deductibles), with a new ceiling as high as $15,600 for individual coverage or $31,200 for a family plan.

The Democrats’ effort to overturn the rule is the definition of a long shot; it would need a majority of votes in both the House and the Senate. But simply forcing a floor vote is likely to be seen as a win by the minority party.

“What Democrats are trying to do is get Republicans to vote on policies that would be unpopular if they rose to the level of public consciousness,” said Adrianna McIntyre, an assistant professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health. “Democrats want to showcase that they want to change these policies, even if don’t have the votes to accomplish it.”

Congress has authority under the review act — enacted as part of a larger law in 1996 — to overturn rules issued by federal agencies. such disapproval resolutions have passed, hundreds have been introduced, often mainly to draw attention to an issue.

It is one of the few levers a minority party has to force action on the floor of the Senate.

That’s because if only 30 senators sign a discharge petition to send the measure to the floor, the Democrats get a vote, without needing to go through a Republican-controlled committee or hold a hearing. A companion resolution is expected to be introduced in the House on June 17.

And there’s no doubt that Democrats will try to use any floor vote on health costs as a litmus test for Republicans in the November elections.

“Time and again Democrats have used Republican efforts to undermine the ACA to their political advantage in campaigns, and this year will be no different,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes ³Ô¹Ï²»´òìÈ.

Polls show that the GOP could be vulnerable if Democrats can convince voters their party would do better on health costs, which are a top concern among voters.

, for example, found that 73% of adults see healthcare costs as a very big problem for the country, leading both inflation and the federal budget deficit. KFF’s tracking polls have found healthcare costs to be a top concern, even among Make America Healthy Again supporters allied with President Donald Trump.

At least half of people who identify as MAHA voters say those health costs on their decision to vote and which party they support.

Medical costs in general typically rise faster than inflation, driven by increased hospital and doctor bills and use of drugs, devices, and other healthcare. That leads to higher costs for employers that offer health plans to their workers and for taxpayer-supported programs such as Medicare and Medicaid, as well as higher premiums for insurance plans sold under the ACA. The consultancy PwC projects the cost to treat patients this year will , the highest in nearly two decades.

Higher premiums and lower subsidies also hit many ACA enrollees this year, with about 1.2 million fewer sign-ups than for 2025 as of January.

Costs “are a good Democratic talking point,” said Joseph Antos, a former government health official who is now a senior fellow emeritus at the right-leaning American Enterprise Institute. “Trump was going to solve inflation, and instead, what do we have?”

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Sign-ups were already down in January by about from last year’s . For this year, enrollees then faced premiums that increased, on average, . On top of that, subsidies that help people purchase coverage shrank or vanished.

Now experts are watching how many of the approximately 23 million people who enrolled will fail to pay their share of premiums.

While available data on premium payments is mainly from January, a few states that run their own ACA markets have released information for later months. The sharpest drop in people paying premiums, based on limited data, is , which saw a 28% drop in April compared with the same period a year ago, according to an analysis by Charles Gaba, a healthcare policy analyst and blogger who specializes in the ACA.

The news website NOTUS that it had internal Centers for Medicare & Medicaid Services data showing that roughly 21% of people using the federal ACA marketplace — — failed to pay their share of January premiums, which, if correct, is far higher than at the same time last year.

CMS did not answer questions from ³Ô¹Ï²»´òìÈ about the enrollment data.

In looking at the early numbers analysts released, “we can’t yet quantify how much worse it will be than in previous years, but it will absolutely be worse because of the sticker shock,” said Ellen Montz, a managing director with the Manatt Health consultancy, who helped oversee the ACA during her tenure with the Biden administration.

The initial results come amid rising public concern about affordability, that are often .

A KFF analysis , for instance, found that the average ACA plan deductible saw the steepest increase in history — growing by 37%, or over $1,000, from $2,759 in 2025 to $3,786 in 2026 as enhanced premium tax credits expired.

Those rising costs pose a political challenge for President Donald Trump and the broader GOP, which has opposed enhanced subsidies to help people purchase Obamacare coverage. Republican lawmakers also passed a spending package last year — enacted as the One Big Beautiful Bill Act — that included provisions expected to reduce ACA enrollment and fueling higher premiums this year.

The enrollment reductions “are real people with real consequences,” Montz said. “The Affordable Care Act is a political lightning rod, but it’s a critical component of the coverage landscape.”

Following the Numbers

Right now, the drop-off rate aligns with what some policy experts predicted, partly because Congress did not extend generous benefits that expired at the end of last year. Those enhanced subsidies had been in place since 2021.

“Overall, the individual market does appear to be trending toward a significant contraction in 2026, and may well resemble” drops projected by the , said a , an analysis arm of the HMA Co.

Based on its analysis, drawn from data provided by 75 insurers, Wakely estimates that average ACA enrollment will end up being 17% to 26% lower this year than last.

So far, the Wakely report says, an average 86% of enrollees made their first payment in January.

Failure to pay premiums varied by state. Those with the lowest drop-off rates had enacted additional help — such as backfilling part or all of the reduced subsidy amounts with state money — or experienced lower premium increases. States that run their own exchanges had higher payment rates (92%) than those served by the federal marketplace (82% to 84%).

Gaba’s initial analysis of data includes more recent numbers from nine of the 20 states that run their own Obamacare marketplaces.

“Georgia could be fairly representative” of other states that did not enact additional protections, Gaba said. For example, payment failure rates, year over year, were 11.6% as of April in New Jersey, and, as of February, 15.7% in Washington state and 8.5% in California.

Only one state in his sample — New Mexico — saw an increase in the percentage of people making premium payments, according to the latest available monthly data. Unlike most, it to fully make up for the lower federal subsidy amounts.

Enrollment figures for the ACA are never static. Traditionally, more people sign up — either through auto reenrollment or by taking initiative to shop — than actually pay premiums, so the numbers tend to be higher at the start of the year.

People drop out over the course of a year for many reasons, such as finding other coverage through a job or by marrying someone with insurance.

Cost, of course, is a factor. This year, because premiums went up and subsidies went down, many people faced what they previously paid toward their coverage.

And the Trump administration ended a special enrollment program that let low-income people enroll year-round.

drops should not be seen solely in the context of rising costs. Paragon Health Institute, a free-market think tank that has become influential among conservatives on Capitol Hill, has long argued that record enrollment numbers in recent years were fueled by fraudulent sign-ups, perhaps in the millions.

, , and policy experts took issue with the methodology Paragon used to estimate improper enrollments, saying they likely were vastly overestimated.

In a , the organization’s president, Brian Blase, doubled down on the fraud findings. Using data that detailed how many people failed to make premium payments each year, on average, from 2014 to 2019 — the year before covid emerged and two years before enhanced subsidies kicked in — he offered this prediction for 2026: About 19 million people would be enrolled by year’s end. Even at that, the note says, the “market would be 90% higher than the pre-COVID average.”

For other experts, however, the biggest explanation for falling enrollment is cost.

Some people had never experienced the ACA before the enhanced tax credits kicked in, so they faced extra sticker shock.

“In economic theory, no matter whether one is left, right, or center, it’s a simple fact that when you raise prices of something, fewer people will buy it,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

The Long View

The expectation of a lower enrollment trend holding up is one of the key factors likely to translate into higher cost estimates as insurers draw up 2027 rates.

For one thing, though it is still unclear how many people will stay enrolled, it is also unknown whether those enrollees will submit more medical claims than insurers projected. It’s generally thought that younger or healthier people are more likely to drop coverage when faced with growing premiums.

Secondly, there has been a sharp shift by consumers to purchase bronze-level plans, which have smaller monthly premiums but higher deductibles — the amount people must pay out-of-pocket for most treatment, except preventive care, before insurers pitch in. The found that sign-ups for bronze plans jumped from 30% to 40% of total plan selections — growing from 7.3 million in 2025 to 9.2 million people this year. Will they pay? Or will hospitals and doctors be on the hook for uncollected copays or deductibles, and then raise prices to compensate?

Insurers base their premiums, in part, on such analyses.

Another troubling factor for actuaries is the late posting of a key regulation that sets the next year’s rules for ACA health plans. The initial 2027 proposal from the Trump administration came out in mid-February and included aggressive new ideas — such as sharply increasing deductibles for certain types of ACA plans or allowing insurers to offer plans with no set networks of medical providers. It was , well into the time when insurers are calculating premiums for the following year. Many of the proposed changes, with some modifications, were approved, such as allowing for higher annual deductibles in some types of coverage.

“This is definitely a challenging year to be an actuary,” said Louise Norris, a health policy analyst for healthinsurance.org, a consumer information and referral website affiliated with Trove Group, an insurance agency.

“We know for sure that the individual market has gotten smaller and almost certainly sicker, as the people dropping coverage are more likely to be healthy.”

While they “aren’t waving huge red flags” yet, insurers are closely watching trends, said Michelle Anderson, a director at Wakely and co-author of the recent report.

Anderson does not expect an average 26% premium increase like the one seen this year.

Still, Anderson expects the ongoing uncertainty and predicted decline in enrollment, which will vary by state and insurer, to play a role in setting next year’s premium rates.

“It would not surprise me if there were some double-digit increases,” Anderson said.

³Ô¹Ï²»´òìÈ reporter Rachel Spears contributed to this article.

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More than 80 of his customers who were enrolled in the same Medicare supplemental plan from the insurer Chubb got hit last August with a 45% increase.

“In my 49 years of doing biz as a broker, I’ve never seen a premium increase be effective immediately on everyone, instead of on their policy anniversary,” said Jaggi, whose brokerage scrambled to find more affordable options for clients. The policies pick up deductibles and other costs not covered in traditional Medicare, and without one there is no upper limit on how much a consumer might owe each year.

While 45% was an unusually big jump, Jaggi and other brokers say double-digit premium increases for Medicare supplemental, or Medigap, policies are becoming the norm.

A Chubb spokesperson did not respond to requests for comment on the increase.

More than 12 million people — of those in traditional Medicare — buy a Medigap policy. Others rely on some sort of retiree employer coverage or a different backup. About 13% of people in traditional Medicare don’t have supplemental coverage, according to KFF, meaning they could be vulnerable to large costs if they have a serious illness.

In the supplemental market, following big increases last year, rates appear to be rising again. In early 2026 filings with state insurance commissioners from Aetna, Blue Cross Blue Shield, Cigna, Humana, Mutual of Omaha, and UnitedHealthcare, rate increases for Plan G policies — the most commonly purchased supplement type — ranged from just in the first quarter, according to Nebraska-based consulting firm Telos Actuarial.

“While this is a small dataset across a select number of states, it’s an indication that carriers are looking to correct their premium rates in light of upward pressure on their claims experience,” said Brett Mushett, a consulting actuary with Telos.

Climbing Numbers

Premium rates vary based on the type of coverage chosen, where a beneficiary lives, and their age. For Plan G coverage, beneficiaries paid an in 2023, according to KFF. That amount has likely risen since.

“In some states, like Ohio, Medicare supplements for years would have a 3% to 5% year-over-year increase. Now it’s 10% to 15%,” said Amanda Brewton, owner of Medicare Answers Now, a marketing organization whose clients are sales agents.

In Alaska, Premera Blue Cross raised the premiums on its Plan G policies by nearly 12% for this year, according to rate sheets provided to ³Ô¹Ï²»´òìÈ by insurance agent Patricia Mack, who said another insurer raised rates by nearly 13%.

For example, a 65-year-old woman who last year would have been charged $172 a month for a Plan G policy would now face a monthly rate of $192, said Mack, who owns Alaska Insurance Benefits in Wasilla.

Premera spokesperson Courtney Wallace said in an email that Medicare makes changes to deductible and copayment rates each year, which affects supplemental plans that cover those increasing amounts.

Wallace also noted that the insurer saw higher medical service use among its members, “which further drove claims costs and ultimately impacted premiums.”

Agents and policy experts blame a range of factors for rising premiums: an increase in the use of medical services by beneficiaries; the aging of the population; increases in labor and medical costs; rules in some states governing Medigap plans; and people’s enrolling in — or getting out of — private Medicare Advantage plans.

“Five years ago, it was exceedingly uncommon to have a carrier with a rate increase of more than 10%. Now it’s very uncommon to see a rate increase below 10%, and it’s not uncommon to see it over 20%,” said Chalen Jackson, vice president for government affairs at Integrity, a Dallas-based company that sells life and health insurance.

Jaggi, who co-owns Jaggi Petry Insurance & Investments in Forsyth, Illinois, along with his daughter, said he eventually found other options for many of those 80-plus clients with the large increase, which came from an insurer that had previously been the lowest-cost option. But it wasn’t easy — and continuing increases are expected.

“These are unbelievable increases,” said Jaggi, who said he is seeing premium hikes exceeding 15% this year across a range of insurers.

Policy experts have outlined possible solutions, including for Congress to cap out-of-pocket costs for Medicare beneficiaries or subsidize the purchase of Medigap coverage.

“Traditional Medicare is the only federal health insurance program without an out-of-pocket cap,” Sen. Ron Wyden (D-Ore.) wrote in an email, adding that the program “needs to be updated and strengthened to protect the Medicare guarantee for American seniors.”

But making changes to Medicare that require congressional approval is unlikely in the current legislative environment, especially because adding an out-of-pocket cap would add costs to the federal budget.

How This Plays Out

People generally qualify for Medicare when they turn 65. Beneficiaries after they initially enroll in the traditional fee-for-service program to purchase a Medigap plan at standard rates without having to answer health-related questions.

Strict rules then kick in around when beneficiaries can enroll in or switch Medigap coverage and options become much more limited, with each one generally involving trade-offs or tough choices.

have what’s known as a “birthday rule,” which requires insurers once a year to allow people enrolled in a Medigap plan to change to different supplemental coverage — usually around their birthdays — without being medically underwritten. Those rules can help consumers, including those with health conditions, to switch.

An additional — Connecticut, Massachusetts, Maine, and New York — require insurers to offer at least one Medigap policy to all applicants either year-round or during an annual enrollment period, depending on the state. Changes are allowed no matter the person’s health.

Another option for those facing high Medigap costs is to leave traditional Medicare and enroll in a private-sector Medicare Advantage plan, which have out-of-pocket caps. But joining one means beneficiaries must generally rely on a set of in-network doctors and hospitals. And if they change their mind and want to go back to traditional Medicare, they have only a 12-month window in which to purchase a Medigap plan without passing health questions. After that, it can be more difficult.

“A lot of people don’t know that if they are in Medicare Advantage for a year, they can get turned down by a Medigap plan or charged really high premiums because of a preexisting condition, which for many people effectively traps them in MA plans,” said , a research associate at the liberal Center for American Progress and co-author of a on the issue.

There are some exceptions. For example, if a Medicare Advantage plan withdraws from a market or leaves the Medicare program, its enrollees can qualify for a supplemental plan without being asked health questions or charged more for having preexisting conditions.

For this year alone, about 2.6 million people when their insurer pulled out of their markets, according to KFF, and more than a million lost coverage for 2025. Many switched to other MA plans, but “somewhere around 440,000 of those people did go to a Medicare supplement policy,” sometimes because there was no other MA plan in their area, said George Dippel, president of Deft Research, a Minneapolis-based market research organization focused on insurance for older people. Deft is part of Integrity, the Dallas company.

Some Medicare experts note that anytime insurers enroll people whose health status they can’t consider — whether because of birthday rules or because their Medicare Advantage plan left the market and thus qualified them for an exemption from medical underwriting — it potentially exposes them to more health care utilization and higher costs, making them more likely to increase premiums across the board to offset the possible financial hit.

Another option mentioned by brokers for people looking to lower their costs is to consider one of the two types of Medigap plans that come with a deductible, which is currently just under $3,000 for a year. Those plans charge far lower monthly premiums than Medigap plans that pick up a much larger portion of annual amounts people must pay toward their Medicare services.

Still, “a lot of people are not comfortable with a $3,000 deductible,” Mack said.

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More changes lie ahead that make it important for those getting subsidies in 2026 to track their income and take steps to protect against that kind of financial hit.

First, the basics of how the subsidies work.

Enrollees pay a percentage of their household income toward their health insurance premiums based on a sliding scale, ranging in 2025 from nothing for very low-income people to 8.5% at higher income levels. Subsidies, usually paid directly to insurers, cover the rest.

The income calculation done during open enrollment is an estimate of what a household thinks it will earn in the coming year. At tax time, ACA enrollees must reconcile what they received in subsidies with what they actually earned. If their income rose, they might owe some of the subsidies back.

But don’t skip filing! People who get ACA subsidies must file tax returns no matter their income, and that is becoming even more important: The Trump administration people from subsidy eligibility if they have gone two consecutive years without filing, and it is proposing lowering that to one year.

Beware Surprise Tax Bills

All enrollees who received subsidies for ACA coverage in 2025 — — need to include a special form, the , with their tax filings. That form is used to reconcile a person’s actual income with the amount of subsidies they received, information the IRS mails them on a separate, . Subsidy amounts are based in part on the income projections they made when they enrolled in their ACA plans.

And that can lead to surprises. Some may find they get money back if their income was less than they estimated. But, if their income went above their initial or updated estimates, they probably qualify for less in assistance and will have to pay money back.

Groups that help people file their taxes say it’s not always easy for people to accurately estimate their income for the year ahead, especially those who run their own businesses, work multiple jobs, or have work that comes with varying hours.

Clients will say, “I can make anywhere between $20,000 and $45,000 next year. I just don’t know,” said Katie Alexander, director of training and volunteers for the health and economic opportunity program at Pisgah Legal Services, a western North Carolina nonprofit that provides free tax and health insurance help to people with low incomes.

Still, for taxes being filed now for the 2025 tax year, on what many people must repay.

That cap is $375 for a single individual who earned less than $31,300 in 2025, or . The maximum owed under that sliding scale for people whose income is on the higher end of the range is $1,625 for an individual and $3,250 for a family.

There is no repayment cap for people earning more than four times the federal poverty level — totaling $62,600 in 2025 for an individual or $106,600 for a family of three — so they could owe back all amounts that exceeded their eligibility.

“The amount is just so staggering for folks,” Alexander said.

One woman whom Pisgah staff helped with pulling together her taxes for 2025 made just above $50,000, which was more than she initially estimated. Her repayment was capped at $1,625, Alexander said. Without that cap, she would have owed $4,000, a substantial chunk of her annual income.

Plan Ahead: The Rules Will Be Tougher Next Tax Season

Congressional Republicans’ One Big Beautiful Bill Act, signed into law by President Donald Trump last summer, . That means come next year’s tax season, there will be no sliding-scale limit to how much people could owe back in subsidies for 2026 if their income exceeds their projections.

“That’s just going to be absolutely devastating,” Alexander said.

There are at least two other things to keep in mind, both stemming from covid-era enhanced tax credits, which expired at the end of last year because Congress did not extend them. One is that the amount of household income people must pay toward their premiums this year before subsidies kick in has risen to just over 2% on the low end of the income scale and up to nearly 10% for higher-income earners.

The second is that households earning over four times the federal poverty level no longer qualify for ACA subsidies.

The biggest financial hit could be felt by enrollees whose income rises enough during the year to exceed four times the poverty level. In that case, they would owe back all the subsidies they receive in 2026.

And that could be a lot.

In 2025, for example, the average monthly premium for ACA coverage was $619, but the average enrollee received subsidies worth enough to offset all but $74 of that, according to the .

There’s another twist for some. Because the enhanced credits were not extended, people are paying, on average, double the amount toward their premiums this year, so they may be looking to add to their incomes to cover the cost. A found that 43% of people who remained enrolled in coverage this year are planning to work more hours or get additional work to cover those costs.

“That makes sense, but it can also present a risk of being eligible for less subsidy money than they thought, or even mean they would have to repay the entire tax credit,” said Cynthia Cox, senior vice president and director of the Program on the ACA at KFF, a health information nonprofit that includes ³Ô¹Ï²»´òìÈ.

People can update their projected income at the marketplace website as it changes during the year.

Pisgah staff are calling people they’ve worked with and saying, “Please, please, please, if your income changes, call us so we can adjust your income through the marketplace,” Alexander said.

As much as possible, keep track of income during the year. This isn’t easy, especially for workers who don’t have a job with regular paychecks.

“If you’re meeting with a CPA to talk about taxes, have a conversation to make sure you’re making enough money to afford your costs, but not too much to lose eligibility for a subsidy,” Cox said. “Contributing toward a retirement plan or a health savings account can lower part of your income that counts toward subsidy eligibility.”

Others might choose to dial back their work hours or forgo a new client contract.

“If taking that extra shift means putting you over the line of 400% of the federal poverty level and that’s going to cost you $10,000 in repayments, maybe don’t take that shift,” said Jason Levitis, a senior fellow at the Urban Institute who follows ACA and tax policy issues.

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Now, the Trump administration in reducing the problem while simultaneously saying more controls are needed.

It has proposed a for next year, including stepped-up requirements for some applicants to prove eligibility for subsidies or enrollment and new scrutiny of sales agents and marketing practices.

While there is a general acknowledgment that there is fraud in the ACA marketplace, some health policy analysts say these new requirements miss that mark and instead will make it harder for people who are eligible to enroll.

“There is a trade-off, particularly with the provisions focused on consumers, that maybe it will prevent some fraudulent enrollment, but also potentially a large number of valid applicants,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at the Brookings Institution.

In its proposal, though, the administration expresses optimism that efforts already in place will continue to pay off, despite the fact that the number of complaints about unauthorized enrollment or switching rose to 341,906 in 2025, compared with 229,734 the year before Donald Trump took office. Still, according to the rule, “program integrity measures implemented during the past year,” along with the expiration of enhanced tax credits, “are likely to lead to a decrease” in complaints in 2026.

The end of those tax credits also means the amount people pay toward their coverage has increased. Data released Jan. 28 by federal officials showed a year-over-year  enrollments across the federal healthcare.gov marketplace and those run by states. And from KFF, a health information nonprofit that includes ³Ô¹Ï²»´òìÈ, found that of those who remained covered this year, 80% said their premiums or other costs are higher than they were last year, with 51% saying they are “a lot higher.”

Katie Keith, a director at Georgetown University’s O’Neill Institute for National and Global Health Law, said the administration was sending mixed messages, on one hand “talking about its fraud-fighting efforts” being successful, but releasing a proposed rule “that says we have to have all these restrictions on consumers because of fraud.”

Closing Consumer Windows

Last year, the Trump administration reversed some of the Biden administration’s ACA efforts, including eliminating a special enrollment period for low-income people that let them sign up year-round.

This year’s rule includes proposed changes aimed at preventing people from fudging their incomes — higher or lower — to qualify for subsidies.

For instance, applicants whose federal data shows they were previously below the poverty level — and thus not eligible for subsidies — would have to submit additional income verification to show they expect to earn above the poverty level in the coming year.

Another part of the proposed rule would require the federal marketplace, used by 30 states, to step up verification efforts for people who want to sign up outside of the ACA’s annual open enrollment period, for reasons including getting married, adopting a baby, or losing other coverage. Currently, the marketplaces conduct such reviews only when people say they qualify because they lost other insurance, according to an .

The income verification requirements “will be burdensome,” she said.

Some ACA applicants, especially those running small businesses or working several part-time jobs, find it more difficult to estimate or document their anticipated income and might find they’re prevented from getting subsidies, Keith and other analysts said.

These proposals are among policies reprised from last year’s ACA rule and initially intended to take effect in 2026. But several cities filed a lawsuit to challenge those regulations. The judge overseeing the case pending its outcome.

In his order issuing a temporary stay, questioned whether the government adequately responded to questions about the accuracy of data it used in citing widespread fraud.

Additionally, many of the provisions purportedly targeting fraud are “unsupported by data showing that if enacted, they will, in fact, reduce any such fraud,” the judge wrote.

The proposal for 2027 has “new supporting information since the original policies were established” that includes clarifying what documentation is needed for some of the verification processes, Centers for Medicare & Medicaid Services spokesperson Catherine Howden said in an email. In addition, she said that CMS is now reviewing public comments that have been submitted before finalizing the provisions.

Targeting Fraud by Agents, Marketers

Critics of the ACA argue that more-generous subsidies put in place as a response to the covid pandemic, in addition to other changes during the Biden administration, led rogue brokers to enroll or switch people without their consent, seeking to collect commissions. That could be done easily, critics say, because with many plans, subsidies covered the entire premium. The lack of a monthly bill made it easier to sign people up without their knowledge — a long-running problem . When that happens it can leave people unable to access their coverage .

Those expanded subsidies have now expired, but the administration’s proposed rule would still add requirements for agents. For example, they would be barred from providing cash or most other freebies as incentives to enroll, have to use a standard consent form that must be signed by the consumer, and be held responsible if they hired a marketing firm that used questionable advertising to lure customers. That includes touting nonexistent gift cards or making websites look like official government ACA portals. Such websites would have to be removed.

“This would help ensure no additional consumers would see the advertisement and be misled,” the proposal says.

Insurance agents told ³Ô¹Ï²»´òìÈ that some of the proposals, such as delineating what counts as a misleading marketing effort, are good first steps but might not fully address concerns about unauthorized enrollment.

It doesn’t “address all the system vulnerabilities,” said Jason Fine, who runs a brokerage in Florida. He said he has filed more than 100 reports about unauthorized rivals accessing his clients’ coverage over the past two years but has yet to see any of those agents removed from the federal marketplace.

More than 850 agents had their certification suspended with little notice in late 2024 under the Biden administration, which said it was looking into complaints about them. The Trump administration told the Government Accountability Office in May that it had reinstated all or most of those agents to fulfill its “statutory and regulatory” responsibilities, according from the independent oversight group. The report, which outlined long-running fraud problems in the ACA, noted that CMS would continue to monitor those agents and could take “further enforcement action” against them.

Another Biden rule, this one aimed at combating unauthorized sign-ups, remains in place and requires agents to have three-way calls with the client and a federal marketplace call center representative for some enrollments or plan changes.

But Fine and other agents said bad actors are finding ways around that requirement, including by faking that they are the customer during the calls. That contention is backed up in the administration’s new proposal, which notes that federal regulators have received reports that some brokers “may be using artificial intelligence to impersonate consumers and falsely attest to household income.”

Still, the proposal does not include some of the measures agents say would improve the situation.

Fine, for example, said the federal marketplace should more proactively flag unusual activity on consumer accounts, such as multiple agent changes or switches to new insurers within a short period of time, or changes made in the dead of night.

“Overnight is when a lot of this fraud occurs,” Fine said. “No one is changing their insurance at 4 a.m., and that should trigger an automatic fraud alert.” He also wants to see a proposal to rein in overseas call centers that contact U.S. residents — often repeatedly, sometimes making claims about free gift cards or other nonexistent perks — then send their information to agents looking to enroll them or switch their ACA plans.

Others, including Ronnell Nolan, president of Health Agents for America, have also long called for two-factor authentication, similar to what banks require, to confirm that enrollments or switches are approved by the consumer. The 20 states, plus the District of Columbia, that run their own marketplaces incorporate additional measures, including two-factor authentication, few of the types of problems that the federal market has seen, Nolan said. The administration’s proposed rule does not call for this protection.

A conservative think tank, the , estimates there are several million fraudulent enrollments, but other groups — including the GAO, using a different methodology — have put the estimate far lower.

Based on its preliminary analysis, the GAO estimated there were “at least 160,000 applications in plan year 2024 that had likely unauthorized changes,” representing about 1.5% of all applications.

Meanwhile, Brookings’ Fiedler said the debate around the proposal highlights an ongoing question — not just how much fraud exists or what to do about it, but “how much government should help people get covered at all.”

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Still, 69% of those enrolled last year signed up again this year, often for less generous coverage. About 9% said they had to forgo insurance, according to the survey by KFF, a health information nonprofit that includes ³Ô¹Ï²»´òìÈ.

The KFF poll revisited the people who responded to of Affordable Care Act enrollees during open enrollment for ACA plans.

Steve Davis, a 64-year-old retired car salesman in Rogersville, Tennessee, who participated in both polls, said he was looking at an annual premium of about $14,000 to renew his ACA coverage this year. He didn’t qualify for enough of a tax credit to defray the cost, he said, after Congress gridlocked on an extension of more-generous subsidies put in place under President Joe Biden.

But things worked out for Davis. He landed a job at a convenience store that came with insurance, with his share costing about $100 more a month than the $300 he paid for an ACA plan last year, before the enhanced tax credits expired.

“As it happened, the Lord provided and my insurance kicked in through my employer,” he told ³Ô¹Ï²»´òìÈ.

In the November survey, many respondents were not sure what they would do for their health insurance in the coming year.

Some were waiting to see whether Congress would extend the enhanced premium subsidies, which had helped many people get lower-cost — or even zero-cost — health premiums.

Congress’ inaction left some consumers in a bind.

Now, the new poll found, affordability issues are hitting home as the midterm election approaches. And that might play a role in competitive districts, creating headwinds for Republicans.

Midterm Signals

Across all respondents who were registered to vote, the poll found more than half place “a lot” of blame for rising costs on Republicans in Congress (54%), with a similar share putting the same level of blame on President Donald Trump (53%). A smaller group placed a lot of the blame on congressional Democrats (34%). Among independents, a group expected to be a key factor in many districts, the percentages putting a lot of the blame on the GOP (56%) and Trump (58%) were higher.

Among Republicans, 60% placed a lot of the blame on Democrats in Congress.

“Those who have marketplace coverage, who remained on it, they’re really struggling with health care costs,” said Lunna Lopes, senior survey manager for KFF.

While more than half (55%) of returning ACA enrollees said they will have to pare back on other household expenses to cover health care costs, about 17% said they might not be able to continue paying insurance premiums throughout the year.

Overall, 80% of those who reenrolled for 2026 said their premiums, deductibles, or other costs are higher this year than last, with 51% saying they are “a lot higher.”

About three-quarters of ACA enrollees in the survey who were registered voters said the cost of health care will have an impact on their decision to vote — and on which party’s candidate they support.

Democrats were more than twice as likely as Republicans to say those costs will have a major impact on their decision.

“Democrats seem particularly more energized by health care costs than their Republican counterparts,” Lopes said.

Enrollment Tally Down

Data released Jan. 28 by federal officials showed that about 23 million people enrolled in Obamacare plans across the federal healthcare.gov marketplace and those run by states, about 1.2 million fewer than in 2025.

But it isn’t yet known how many are paying their monthly premiums on time, and many analysts expect overall enrollment numbers to fall as that data becomes available in the coming months.

For most people, having to pay more for premiums this year was mainly due to the expiration of the enhanced tax cuts, pollsters noted. Because the subsidies that remain are less generous, households have to pay more of their income toward coverage. Congressional inaction also meant the restoration of an income cap for subsidies at four times the poverty level, or $62,600 for an individual, sticking people like Davis with higher bills.

Not everyone saw increases.

Matthew Rutledge, a 32-year-old substitute teacher in Apple Valley, California, who participated in both KFF polls, said he qualified as low-income and his subsidies fully offset his monthly premium payment, just as they did last year. He does have copayments when he sees a doctor or accesses other medical care, but he told ³Ô¹Ï²»´òìÈ that “as long as the premium doesn’t go up, I’m fine with it.”

Rising premiums are fueled by a variety of factors, including hospital costs, doctors’ services, and the prices of drugs.

To lower premiums, insurers offer plans with higher deductibles or copayments. In the ACA, plans with lower premiums but higher deductibles are called “catastrophic” or “bronze” plans. “Silver” plans generally balance premiums and out-of-pocket spending, while the highest-premium plans with lower deductibles are “gold” or “platinum.”

About 28% of those who stayed in the ACA marketplaces switched plans, the pollsters noted.

One 56-year-old Texas man told pollsters that his family’s income exceeded the cap for subsidies, so they switched down from a gold plan to a bronze. “Even doing that, our premiums are three times what they were in 2025, with lower plan features and a higher deductible,” he said, according to a KFF poll news release.

For some, reenrolling was not a viable option.

In addition to the 9% who said they are now uninsured, about 5% said they switched to some type of non-ACA coverage.

Some people, like Davis, landed job-based coverage, while others found they qualified for Medicaid, the joint state-federal program for low-income residents.

Such churn in and out of ACA coverage is not unusual, Lopes noted. “People get a job. They get married. They age into Medicare,” the program for older or disabled people, she said.

The poll highlighted that many people dropping coverage were younger, between 18 and 29. About 14% of people in that range now say they are uninsured. 

That’s not surprising, given that younger people tend to use health coverage less. ACA insurers said one reason they raised premiums this year was because they expected more young or healthy people to drop out, leaving them with a higher share of older, more costly enrollees. Among those 50 or older, the poll found that only 7% are now uninsured.

GOP critics of the now-expired enhanced subsidies say they were always meant to be temporary. Extending them would have cost about $350 billion from 2026 to 2035, .

But not extending them means more people will become uninsured. The CBO said the extension would have meant 3.8 million more people having insurance coverage in 2035.

KFF pollsters, in February and early March, surveyed 1,117 U.S. adults, more than 80% of the ACA enrollees originally polled in November, online and by telephone. The margin of error is plus or minus four percentage points for the full sample.

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“I call it the unaffordable care act,” he said. He reprised the line in his address, blaming “the crushing cost of health care” on Obamacare.

Trump’s words also play off an ongoing congressional debate that began late last year with the expiration of the enhanced tax subsidies that had lowered the cost of ACA insurance for millions of Americans — and thrust the issue of ACA-related costs back to center stage.

Without those enhanced subsidies, the amount people pay toward monthly Obamacare premiums doubled, on average. The number of people enrolled in ACA coverage for this year has dropped by more than a million, and experts say more people could abandon coverage once premiums come due. Democrats are using this development to crank up the heat on Republicans ahead of the November elections and steer the conversation on the affordability issue.

Republicans fault the law itself for driving up these costs. For instance, Rep. Mike Lawler (R-N.Y.) that premiums “skyrocketed across the country since it took effect.”

Critics routinely point to several provisions within the ACA as the culprits — among them, essential health benefits, or EHBs. Under the law, Obamacare plans must cover certain essential services, including emergency care, hospitalization, maternity, and prescription drugs, without annual or lifetime dollar limits. But connecting EHBs to the premium increases felt by consumers is not straightforward.

Here’s a primer on key issues involved.

Checking the Numbers

It’s clear that Obamacare premiums have increased.

An analysis by the right-leaning Paragon Health Institute shows that the average premium for a 50-year-old with Obamacare since 2014. The average premium for employer-based plans grew 68% during that same time.

Paragon’s president, , told ³Ô¹Ï²»´òìÈ that this shows the ACA has made health care on the individual market more expensive.

Still, the comparison overlooks a couple of points. Pre-ACA, employer plans generally offered more generous coverage than individual market plans, so work-based coverage cost more. And individual plans were cheaper in part because they could bar applicants with health problems. Beginning in 2014, the ACA forced individual policies to look more like employer plans, covering a broader range of benefits and accepting both healthy and unhealthy applicants. As a result, premiums rose that first year. In the years that followed, ACA plans often experienced faster growth in premiums than job-based plans. Some policy analysts say this isn’t surprising because ACA plans started at a lower dollar base and had more room to rise.

States that saw less dramatic post-ACA premium increases, such as Massachusetts and New York, already mandated that individual-market plans provide EHB-like coverage, noted , a senior research fellow at the Heritage Foundation, a conservative think tank. These states also had higher premiums due to that and other provisions, such as not allowing plans to exclude people with preexisting conditions.

“It was a combination of things,” he said.

Blase acknowledges that the two types of insurance started at different price points. But he said the percentage change over time shows that the ACA faces “underlying inflationary pressures” — including the now-expired, more generous, covid pandemic-era subsidies — that affect its policyholders more so than employer plans.

Aside from that point, however, were on the rise even before the ACA took effect.

An analysis by Jonathan Gruber at the Massachusetts Institute of Technology found that between 2008 and 2010, premiums grew by at least 10% a year and were highly variable across states and insurers.

Consumers’ Other Costs

Over time, ACA deductibles — the amounts policyholders must satisfy in a given year before insurance kicks in — have seen large increases, with “bronze” plans now averaging $7,476 annually, up from $5,113 in 2014, according to KFF, a health information nonprofit that includes ³Ô¹Ï²»´òìÈ. Bronze plans tend to have lower premiums than the other metal-level categories — “silver,” “gold,” and “platinum” — in part because of their higher deductibles.

The Trump administration is doubling down on high-deductible plans as part of its emphasis on affordability, making it easier this year for people age 30 and up to qualify for what are called “catastrophic plans.” These come with even larger deductibles than bronze plans.

The administration pitched a broad regulatory plan for 2027 to cement those changes, saying it was designed to lower premiums and expand choices. It would raise next year’s deductibles for catastrophic plans to $15,600 a year for an individual or around $30,000 for a family. It isn’t clear how popular such plans would be. Detailed enrollment figures for this year are not yet available, but estimates indicate only about 54,000 people chose catastrophic plans in 2025, and consumers can’t use federal subsidies to purchase them.

Before this Trump proposal, though, recent data showed that the rising rate of ACA plan deductibles had not outpaced deductibles for employer plans.

The weighted average — a calculation that gives more weight to ACA plans with the most people enrolled — shows in annual deductible amounts since 2014, from $1,881 to $2,912. During that same period, deductibles in plans offered by 59%, from $1,186 to $1,886, according to KFF’s annual employer survey.

Essential What?

To be clear, the ACA’s catastrophic and bronze plans must cover essential health benefits, as do all Obamacare plans. These EHBs fall into 10 categories of medical services and were included in the ACA to ensure individual policies meet a minimum standard of coverage and are comparable to employer-based health insurance.

Preventive services, such as annual checkups, vaccines, and certain cancer screenings, must be covered at no additional cost to patients. All plans must completely cover the cost of specific vaccines, including the annual flu shot. And insurers cannot refuse to pay for emergency care provided at an out-of-network hospital. Other EHBs are subject to out-of-pocket costs, such as copays at the doctor’s office or pharmacy counter.

In some ways, EHBs save money because they’ve increased access to preventive care, said , a professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health.

Services such as cancer screenings and lab tests can lead to earlier detection of serious conditions, when treatment is less costly, and positive outcomes are more likely.

“If you look down the list of essential health benefits, I think most people would reach the judgment that those are health care services that people should have access to,” said Larry Levitt, KFF’s executive vice president for health policy.

Joseph Antos, a senior fellow emeritus at the conservative American Enterprise Institute, said ACA requirements — such as requiring insurers to accept anyone, regardless of their health status, and limiting insurers’ ability to charge older people more for coverage — also have played roles in boosting premiums.

“Really, it’s practically impossible to tease any one thing out,” Antos said.

States do have latitude to add benefits that fall under the EHB umbrella. For example, bariatric surgery is covered as an EHB in , but not in . Pennsylvania’s EHBs also don’t include hearing aids, but do.

But the Trump administration’s 2027 regulatory proposal : When “states enact benefit mandates, plan premiums must generally increase to account for the additional coverage,” it reads. It also signals that added benefits can raise consumer costs and proposes that states be required to use their own funds to offset some of those costs.

Paragon’s Blase echoed this take in his bottom line. Mandating that plans cover EHBs without annual or lifetime caps, as required under the ACA law, encourages clinicians to overbill and overprescribe, he said. That drives up premiums and means a bigger check for insurers and medical providers at the expense of taxpayers. “You just turn patients into money factories,” he said.

, a senior research fellow at Georgetown University’s Center on Health Insurance Reforms, disagrees, saying that whatever EHBs’ role, they aren’t to blame for the year-over-year premium hikes.

People aren’t consuming medical care at exponential rates just because certain services are now covered: “Me not paying anything for that colonoscopy doesn’t make me want to get more of them,” she said.

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