U.S. — Enrollment in health insurance plans purchased on the Affordable Care Act (ACA) marketplace decreased by approximately 3 million people, falling to 19.2 million in February 2026 from 22.1 million at the end of 2025. This 13% decline marks the largest drop in ACA enrollment since the marketplace was established in 2014 and the first decline since the initial Trump administration.

The Department of Health and Human Services (HHS) attributed the reduction primarily to efforts to combat fraudulent enrollment, stating that these measures partially reversed an increase in such enrollment during the previous administration. The Centers for Medicare & Medicaid Services (CMS) canceled coverage for 250,000 individuals who had enrolled in an ACA plan without their consent. An HHS report issued on June 26 stated, "The Trump Administration has utilized numerous tools mobilizing a full-scale effort to ensure federal subsidies are going only to those for whom they are intended."

Critics suggest that the expiration of enhanced ACA premium subsidies at the end of 2025 was a primary factor in the enrollment decrease. Democrats had advocated for the extension of these subsidies, but the Republican party allowed them to expire.

HHS estimated that improper, phantom, and fraudulent enrollment peaked at 5.6 million people in 2025. The department indicated that program integrity initiatives, including the elimination of certain special enrollment periods and the cancellation of policies deemed fraudulent, led to the reduction of millions of improper enrollments.

The Government Accountability Office (GAO) outlined the risk of fraud associated with ACA subsidies in a December report requested by congressional Republicans. HHS estimates that over 1 million current ACA enrollees do not have a Social Security number.