Obamacare continues to shrink as enrollment opens for 2027

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Holly Hendricks, who is battling an autoimmune disease that leaves her with open wounds down to the muscle, did everything she could to maintain her Affordable Care Act coverage after the enhanced premium subsidies lapsed at the start of this year.

But after a few months, the 49-year-old couldn’t handle paying the monthly premiums, which had more than tripled to nearly $1,100. Hendricks, who also has lupus and rheumatoid arthritis, became uninsured for the first time in April.

While she scrapes together enough money to afford her 12 daily medications, Hendricks can no longer see her four specialists, get blood work, receive infusions or have a wound care nurse tend to her condition. In September, she developed sepsis and ended up in the hospital for a month, which she expects could saddle her with more than $500,000 in medical bills .

Courtesy Holly Hendricks/Luce Divina Photography

“Being insured is catastrophic to my health, but when you have to choose between rent, utilities, food and insurance – the more basic needs have to come first,” said Hendricks, a Sarasota, Florida, resident who works full-time as a caretaker for a veteran.

Faced with soaring premium payments after the beefed-up subsidies expired, millions of Obamacare enrollees left the market at the start of the year. Only 19.2 million people were enrolled as of February, down 2.6 million from the same period a year earlier, according to the latest federal data.

But there are multiple signs that enrollment has continued to fall since then, in part because policyholders like Hendricks couldn’t keep up with the higher monthly premiums amid rising costs for gas , groceries and other necessities.

“People who tried to make it work at the beginning of the year might not be able to make it work for a whole year,” said Cynthia Cox, director of the Program on the ACA at KFF, a nonpartisan health policy research group.

Some folks are hoping to resume their coverage in January if they can find a less expensive Obamacare plan. Open enrollment begins Sunday in most states, but premiums are expected to jump once again.

The ongoing enrollment decline comes as healthcare has been a key affordability issue in the midterm elections. Many Democratic candidates are highlighting that their Republican rivals allowed the enhanced premium subsidies to lapse, as well as voted to slash federal Medicaid funding by roughly $1 trillion as part of the One Big Beautiful Bill Act .

Republican-held congressional districts suffered disproportionately greater drops in enrollment between 2025 and 2026, KFF found. These districts account for 55% of enrollees but 67% of the declines. They tend to have higher shares of lower-income residents, who would have a tougher time affording any premium increases, Cox said.

Eighteen states that run their own Affordable Care Act exchanges reported that enrollment declines accelerated during the year due to more people dropping out and fewer signing up via special enrollment periods in 2026. Disenrollments were up nearly 34% as of May, compared to the same period a year prior, according to a State Marketplace Network report.

The number of people buying coverage on the individual market, which is largely comprised of the Obamacare exchanges, also fell – by more than 4.6 million as of June, compared to the same month a year earlier – according to KFF estimates.

Some states have seen steep declines. Mississippi, for instance, ended 2025 with 338,000 residents enrolled in Obamacare plans. By February, that figure had tumbled to fewer than 192,000 people and fell further to around 125,000 residents in September, Mike Chaney, the state’s insurance commissioner, told CNN. (Enrollment has since edged up to 135,000 people in late October.)

Massachusetts saw its first decline in enrollment during the course of the year outside of the Covid-19 pandemic period, said Audrey Morse Gasteier, executive director of the state’s Affordable Care Act exchange. About 8,000 fewer people were on the exchange in September than in February. The loss stems in part from more enrollees dropping their coverage mid-year than they typically do, she said.

Even New Mexico, which provides generous state-funded subsidies, saw continued disenrollments and fewer people signing up for coverage mid-year. It had been the only state where enrollment increased as of February, but that bump had largely disappeared by the fall, said Brent Earnest, interim CEO of BeWell, the state’s health insurance marketplace.

Kara Windeler is among those who desperately tried to keep her Obamacare coverage, which helped the Clearwater, Florida, resident treat her rheumatoid arthritis, long Covid, severe allergies and other conditions. Her premium jumped to $450 a month, from about $225 last year.

Unable to keep working as a skincare specialist because of her health, Windeler had been selling cherished collectibles, borrowing money from family and draining the proceeds of the 2024 sale of her house to pay her premiums. But the funds ran out so she will be uninsured as of November 1.

To prepare, Windeler filled 90-day prescriptions for her medications, saw her doctors and received a steroid injection in late October. She plans to ration the medicines so they last longer.

Courtesy Kara Windeler

Windeler, an independent voter who turned 50 on Saturday, hopes that the Democrats will act to lower healthcare costs if they win control of Congress.

“There has to be something done so that people don’t die,” she said.

The Centers for Medicare and Medicaid Services, which oversees the Affordable Care Act exchanges, has attributed the enrollment declines to its anti-fraud efforts. It argues it is rooting out so-called phantom enrollees, who don’t exist, and people who were signed up without their knowledge by unscrupulous brokers seeking commissions.

In September, the White House fraud task force announced it was removing 760,000 enrollees from Obamacare coverage.

Premiums for Obamacare’s benchmark silver-tier plans will rise 13%, on average, in 2027, according to a KFF calculation of CMS and state exchange data. It’s the second consecutive year of double-digit premium increases and the 4th largest hike since the Affordable Care Act exchanges launched in 2014, Cox said.

Still, that’s far less than the 58% average jump in the monthly payments enrollees saw this year, which was exacerbated by the expiration of the enhanced premium subsidies. The lapsed assistance was more generous and helped more people than regular Obamacare subsidies, which were part of the 2010 law and continue to exist. Most enrollees still qualify for these regular subsidies, which will help shield them from the standard annual premium increase for next year.

In Idaho, premiums for silver-tier plans will be flat or lower than this year in many parts of the state once subsidies are factored in, said Pat Kelly, executive director of Idaho’s Obamacare exchange. While it’s too early to tell how many people will sign up, Kelly is encouraged by the fact that more people are reaching out to the call center and looking at the exchange’s website since enrollment opened on October 15.

Many enrollees nationwide, however, will have fewer plans to choose from since several large insurers have opted to pull out of some or all of the states where they provide coverage. Roughly 1,200 counties will have only one or two insurers on their exchanges, up from about 800, said Katherine Hempstead, senior policy officer at the Robert Wood Johnson Foundation. That means enrollees could have to switch plans – so they need to check that their doctors and drugs are covered by the new policy.

Plus, those signing up for coverage could have less access to help since the Trump administration has placed a moratorium on new broker and agent participation in the exchanges as part of its fraud-fighting campaign. At the same time, it has slashed funding for navigators, who also provide enrollment assistance, by 90%.

Along with restrictions to immigrants’ eligibility for Obamacare subsidies stemming from the One Big Beautiful Bill Act, this means Affordable Care Act coverage is expected to shrink again next year. Younger, healthier people will likely be the ones to leave first, which could lead to higher premiums for those who remain.

Still, some Americans continue to rely on the Affordable Care Act.

Julie Kay Roberts has been waiting months for open enrollment to begin so she can look for a more affordable Obamacare plan. The consultant from Southlake, Texas, had to drop her coverage in June after being unable to keep up with monthly premiums that had soared from about $490 to $1,240.

Roberts is resigned to having to pay more out of pocket for care to have a plan with lower monthly premiums – even though she considers it more of a backstop in case of a catastrophe such as cancer or an accident. She’s hoping to find a plan that costs no more than $600 a month.

“I definitely will be finding an insurance option of some sort,” she said. “I just I don’t like to go without.”

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霍莉·亨德里克斯患有自身免疫性疾病，导致她身上出现深及肌肉的开放性伤口。今年年初，随着增强型保费补贴的到期，她竭尽所能地维持了她的《平价医疗法案》保险。

但几个月后，这位 49 岁的男子就无力支付每月保费了，保费已经上涨了两倍多，接近 1100 美元。亨德里克斯还患有红斑狼疮和类风湿性关节炎，今年 4 月，他第一次失去了医疗保险。

尽管她勉强凑够钱购买每天12种药物，但亨德里克斯已经无法再去看她的四位专科医生、做血液检查、接受输液治疗，也无法让伤口护理护士照料她的病情。9月份，她患上了败血症，住院一个月，她预计这笔医疗费用可能超过50万美元。

图片由 Holly Hendricks/Luce Divina Photography 提供

“购买保险对我的健康来说是灾难性的，但是当你必须在房租、水电费、食物和保险之间做出选择时——更基本的需求必须放在首位，”亨德里克斯说道。他居住在佛罗里达州萨拉索塔，是一名全职照顾退伍军人的护理员。

由于政府大幅提高的补贴到期后保费飙升，数百万奥巴马医改参保者在年初退出了医保市场。根据最新的联邦数据，截至2月份，仅有1920万人参保，比去年同期减少了260万人。

但种种迹象表明，自那以后参保人数持续下降，部分原因是像亨德里克斯这样的投保人无法承担不断上涨的月保费，而汽油、食品杂货和其他必需品的价格却在上涨。

“年初时试图让这项措施奏效的人，可能无法让这项措施持续一整年，”无党派健康政策研究组织KFF的ACA项目主任辛西娅·考克斯说。

一些人希望如果能找到更便宜的奥巴马医改计划，就能在1月份恢复医保。大多数州的开放注册期将于周日开始，但预计保费将再次上涨。

参保人数持续下降之际，医疗保健已成为中期选举中的关键议题。许多民主党候选人强调，他们的共和党对手不仅让增强型保费补贴失效，还在《一项宏伟法案》（One Big Beautiful Bill Act）中投票削减了约1万亿美元的联邦医疗补助资金。

凯撒家庭基金会（KFF）发现，在2025年至2026年间，共和党控制的国会选区参保人数下降幅度尤为显著。这些选区的参保人数占总参保人数的55%，但参保人数下降幅度却占到了总下降人数的67%。考克斯表示，这些选区往往低收入居民比例较高，而低收入居民更难承担保费上涨带来的负担。

18 个自行运营平价医疗法案交易平台的州报告称，由于更多人退出以及通过 2026 年特殊注册期注册的人数减少，今年的注册人数下降速度加快。根据州市场网络的一份报告，截至 5 月，退保人数比去年同期增加了近 34%。

根据凯撒家庭基金会 (KFF) 的估计，在个人市场（主要由奥巴马医改交易所组成）购买保险的人数也下降了——截至 6 月，与去年同期相比减少了 460 多万人。

一些州的参保人数急剧下降。例如，密西西比州在2025年底有33.8万居民参加了奥巴马医改计划。该州保险专员迈克·钱尼告诉CNN，到今年2月，这一数字已骤降至不足19.2万人，9月份进一步下降至约12.5万人。（此后，到10月下旬，参保人数略有回升至13.5万人。）

马萨诸塞州平价医疗法案（ACA）交易平台执行主任奥黛丽·莫尔斯·加斯泰尔表示，该州今年的参保人数在新冠疫情之外首次出现下降。9月份的参保人数比2月份减少了约8000人。她指出，部分原因是年中退保人数高于往年。

即使是提供丰厚州政府补贴的新墨西哥州，年中也出现了持续的退保和参保人数下降的情况。该州医疗保险市场BeWell的临时首席执行官布伦特·厄内斯特表示，截至2月份，新墨西哥州是唯一一个参保人数增长的州，但到秋季，这一增长势头已基本消失。

卡拉·温德勒是众多竭力想保住奥巴马医改保险的人之一。这位佛罗里达州克利尔沃特市的居民曾依靠这项保险治疗类风湿性关节炎、新冠后遗症、严重过敏症和其他疾病。她的保费从去年的每月约225美元飙升至450美元。

由于健康原因，温德勒无法继续从事护肤专家的工作，她不得不变卖珍藏品、向家人借钱，甚至动用2024年出售房产的收益来支付保险费。但资金最终耗尽，她将于11月1日起失去保险保障。

为了做好准备，温德勒一次性开好了90天的药，看了医生，并在10月下旬接受了类固醇注射。她计划合理用药，让药效持续更久。

卡拉·温德勒供图

温德勒是一名独立选民，周六刚满 50 岁。他希望如果民主党赢得国会控制权，就能采取行动降低医疗保健成本。

“必须采取措施，才能避免人们丧命，”她说。

负责监管《平价医疗法案》医保交易平台的联邦医疗保险和医疗补助服务中心（CMS）将参保人数下降归因于其反欺诈措施。该中心辩称，他们正在清除所谓的“幽灵参保人”（实际上并不存在的人）以及那些被不法经纪人以赚取佣金为由在本人不知情的情况下注册的人。

9 月，白宫反欺诈工作组宣布将 76 万名参保人从奥巴马医改计划中移除。

根据凯撒家庭基金会（KFF）基于美国医疗保险和医疗补助服务中心（CMS）和各州医保交易平台数据的计算，奥巴马医改基准银级计划的保费将在2027年平均上涨13%。考克斯表示，这是保费连续第二年出现两位数增长，也是自2014年《平价医疗法案》医保交易平台启动以来第四大涨幅。

尽管如此，这远低于今年参保人每月保费平均58%的涨幅，而保费上涨的幅度因增强型保费补贴的到期而加剧。已失效的补贴比奥巴马医改法案中规定的常规补贴更为慷慨，惠及更多人群。这些常规补贴是2010年法案的一部分，目前仍然有效。大多数参保人仍然符合这些常规补贴的资格，这将有助于他们免受明年标准年度保费上涨的影响。

爱达荷州奥巴马医改交易所执行主任帕特·凯利表示，在扣除补贴后，爱达荷州许多地区的银级医保计划保费将与今年持平或更低。虽然现在预测注册人数还为时尚早，但凯利感到鼓舞的是，自10月15日注册开放以来，越来越多的人联系呼叫中心并访问交易所网站。

然而，由于几家大型保险公司选择退出部分或全部提供保险服务的州，全国许多参保人的选择范围将缩小。罗伯特·伍德·约翰逊基金会高级政策官员凯瑟琳·亨普斯特德表示，大约有1200个县的医保交易平台上将只有一到两家保险公司，而此前大约有800家。这意味着参保人可能需要更换保险计划，因此他们需要确认自己的医生和药品是否在新保单的承保范围内。

此外，由于特朗普政府为打击欺诈而暂停了新的经纪人和代理人参与医保交易平台，因此，那些注册医保的人可能更难获得帮助。与此同时，政府还削减了90%的医保导航员经费，这些导航员也负责提供注册协助。

由于《一项全面而美好的法案》（One Big Beautiful Bill Act）限制了移民享受奥巴马医改补贴的资格，这意味着明年《平价医疗法案》（Affordable Care Act，简称ACA）的覆盖范围预计将再次缩小。更年轻、更健康的人群可能会率先退出，这可能导致留下来的人保费上涨。

尽管如此，仍有一些美国人继续依赖《平价医疗法案》。

朱莉·凯·罗伯茨（Julie Kay Roberts）等了好几个月，才盼到医保开放注册期开始，这样她就可以寻找更经济实惠的奥巴马医改计划。这位来自德克萨斯州南湖市的咨询顾问，由于无力承担每月保费飙升（从约490美元涨至1240美元），不得不于6月份放弃了之前的医保。

罗伯茨已经接受了需要自付更多医疗费用才能购买月保费较低的保险计划的现实——尽管她认为这更像是一种保障，以防罹患癌症或遭遇意外等灾难。她希望能找到一份月保费不超过600美元的保险计划。

“我肯定会想办法购买某种保险，”她说。“我只是不想没有保险。”