ACA enrollees who lost subsidies left marketplace plans

Clinical takeaway: One-quarter of patients whose state and federal support both ended dropped their plans at year-end, more than double the usual rate. Watch for patients to turn up uninsured or on thinner plans. 

Enhanced federal subsidies made marketplace premiums cheaper and reached households with higher incomes from 2021 through 2025. They expired on December 31, 2025. From 2025 to 2026, marketplace enrollment fell 13%, the largest one-year drop since the Affordable Care Act (ACA) created it. That national count shows the size of the drop but not who was involved. 

Massachusetts is where the expiration should hurt least. The state has the lowest uninsured rate in the US and funds premium help below 400% of the federal poverty level through its ConnectorCare program. It also extended that help to households at 400% to 500% for 2024 and 2025, then ended the extension on December 31, 2025, the same day the federal subsidies expired. That left this group without state or federal help at once. This analysis tests whether year-end plan exits rose in Massachusetts as the support ended, compared with earlier years. 

Year-end plan exits rose in every income group except the lowest. Enrollees between 100% and 600% of the federal poverty level disenrolled at a rate of 15.1% in November and December 2025, versus 11.4% to 12.8% in the same months of 2022 through 2024. 

Exits climbed most at 400% to 500% of the poverty level, where enrollees lost both state and federal support. Among them, 25.0% ended their plans, versus an average of 11.4% in prior years. 

The 100% to 150% group slipped slightly instead. State subsidies kept their premiums from rising. 

Investigators drew on administrative enrollment data from the Massachusetts Health Connector marketplace from November 2022 through January 2026. They compared the share of subsidized enrollees at 100% to 600% of the federal poverty level who ended their plans in November or December 2025, when renewal decisions for the new plan year come due, with the same months in 2022 through 2024. 

Investigators expect larger drops in marketplace enrollment in states that offer no state-funded help. The Congressional Budget Office projects the expiration will leave 3.8 million fewer US residents insured by 2034. 

“These findings offer early evidence that the lapse in enhanced federal subsidies was associated with meaningful marketplace attrition, even under relatively favorable state conditions,” the authors conclude. “Higher rates of disenrollment, or transitions to less generous coverage, may continue as enrollees experience higher premiums. Future research is needed to monitor marketplace enrollment in this changing policy environment.” 

Source: McIntyre A, et al. (2026 Oct 29) JAMA. Massachusetts Marketplace Disenrollment Following Enhanced Subsidy Expiration