KFF survey: Half of returning ACA enrollees say costs are 'a lot higher'; 1 in 10 now uninsured

The enhanced premium tax credits that helped 22 million individuals in the United States afford health insurance through the Affordable Care Act (ACA) Marketplace expired at the end of 2025. Three months later, KFF has fielded the first major survey measuring the real-world fallout.

The survey, published March 19, 2026, found that half (51%) of Marketplace enrollees who re-enrolled for 2026 say their health care costs are “a lot higher” this year compared with 2025. Four in 10 say their premiums specifically are “a lot higher.” In total, a large majority (80%) of returning enrollees report that some combination of premiums, deductibles and cost-sharing has increased.

About one in 10 (9%) of those who had Marketplace coverage in 2025 have dropped it entirely and are now uninsured. Another 28% switched to a different Marketplace plan, with most citing cost as the primary driver.

KFF surveyed 1,117 adults who had ACA Marketplace coverage in 2025, conducting the poll between Feb. 12 and March 2, 2026. The timing is important, as the survey landed about a month after open enrollment ended in most states, but before the grace period for premium payments expires for many enrollees. For most, that comes at the end of March, suggesting the numbers could get worse.

“The impacts on Marketplace enrollees we see in this follow-up survey will likely get worse as people struggle to make payments and the grace period many have expires,” KFF President and CEO Drew Altman, Ph.D., said in a statement accompanying the findings.

The cost shock is real, and enrollees are making painful tradeoffs

The enhanced premium tax credits were first enacted through the American Rescue Plan Act of 2021 and extended through the Inflation Reduction Act of 2022. They dramatically lowered what Marketplace enrollees paid out of pocket for coverage — four out of five consumers on HealthCare.gov could find a plan for $10 or less per month.

When Congress let the credits expire at the end of 2025, KFF estimated that average annual premium payments for those who kept the same plan would more than double.

That estimate appears to be playing out.

The KFF survey found that a majority of returning enrollees (55%) have already cut back or plan to cut back spending on food or other basic household items to afford their health care costs. Among those with chronic health conditions, that number climbs to 62%.

Approximately three in four returning enrollees (73%) said they are worried about being able to afford emergency care or hospitalization costs. Roughly half expressed concern about affording routine medical visits (49%) or prescription drugs (45%). One in six (17%) said they are not confident they will be able to afford their premiums for the full year, putting them at risk of losing coverage later in 2026.

Among those who switched plans or dropped coverage altogether, seven in 10 (71%) said the expense was a “major reason” for the change. A quarter of those who switched plans said they downgraded their metal tier — moving on from, say, a silver plan, in favor of a bronze plan, which lowers monthly premiums but typically means higher deductibles and out-of-pocket costs.

The survey captured the tradeoffs enrollees are making in their own words. A 63-year-old man in California, now uninsured, told KFF: “The end of ACA subsidies caused a huge increase in premiums, the cost of which I could not afford.”

A 56-year-old man in Texas, who downgraded from gold to bronze, said, “Income exceeded the subsidy limit, forcing us to pay the full cost, so we switched down to a bronze from a gold plan. Even doing that, our premiums are 3 times what they were in 2025, with lower plan features and a higher deductible.”

Younger enrollees are leaving and creating a pricing spiral

The survey found that younger adults are disproportionately exiting the Marketplace. Half (49%) of enrollees aged 18-29 reported leaving the Marketplace entirely, including 14% who are currently uninsured.

By contrast, smaller shares of enrollees 50 and older reported dropping coverage — just 7% uninsured.

That pattern matters beyond the individual level. When younger, generally healthier enrollees leave the risk pool, insurers are left covering an older, sicker population, which drives premiums higher for everyone who remains.

KFF noted that insurers anticipated this dynamic and raised premiums more than they otherwise would have, factoring in the expectation that healthier adults would disproportionately drop coverage once the subsidies ended.

The consequences of a growing uninsured population

The coverage losses documented in this survey are part of a broader trend that physicians are already starting to feel.

Medical Economics spoke with Brian Outland, Ph.D., director of regulatory affairs at the American College of Physicians (ACP), at the ACP Internal Medicine Meeting 2025 in New Orleans. Outland spoke bluntly about the clinical reality when patients lose coverage. "Physicians love their patients," he said. "Just not being able to see them because they don't have insurance is quite heartbreaking."

The ACA Marketplace isn't the only source of coverage losses. The One Big Beautiful Bill Act (OBBBA), the federal spending law signed in July 2025, introduced Medicaid work requirements and tightened eligibility rules, which are expected to push additional millions off coverage.

The Congressional Budget Office has projected that the OBBBA alone could leave approximately 10 million more people uninsured over the next decade through Medicaid cuts and other coverage changes. That comes on top of an estimated 4.2 million projected to lose coverage due to the expiration of the premium tax credit, which was not addressed in the law. KFF has estimated the combined total could reach 17 million uninsured as early as this year.

The law also ends automatic renewal for Marketplace plans, meaning every policyholder will need to actively re-select coverage each year. Combined with new income verification procedures, that change is expected to cause additional coverage losses through administrative churn alone.

A look at Texas 2036

Several of the KFF survey's most striking respondent quotes came from Texas, which has long carried the highest uninsured rate in the country. Texas is also one of 10 states that have not expanded Medicaid under the ACA, meaning many low-income residents who might otherwise qualify for Medicaid are instead relying on Marketplace coverage with premium tax credits. With those credits now diminished, a particularly vulnerable population faces a widening coverage gap.

Charles Miller, J.D., director of health and economic mobility policy for Texas 2036, discussed the state's unique challenges in a recent interview on Off the Chart: A Business of Medicine Podcast. Miller's organization conducted in-depth research on who the uninsured in Texas actually are and found a significant disconnect between what people thought coverage would cost and what it actually cost — particularly when enhanced subsidies were still in effect.

"A lot of folks who were eligible for free, or, say, under $25 a month plans, had a perception that they were going to have to pay $300 or $500 a month," Miller said. Some of those perceptions were based on past experience with higher prices, he noted, while others were shaped by media coverage or political attitudes toward the ACA.

Miller estimated that when the enhanced subsidies were in place, roughly 40% of the state’s 5 million uninsured residents were eligible for a free plan. Those numbers have since declined with the expiration of the credits, though he said more than a million uninsured Texans were still likely eligible for a free plan at the time of the interview.

A 34-year-old Texas man in the KFF survey described his decision to go uninsured, saying, "The prices are simply too high. $800/month for the absolute cheapest plan for two people. Our income is $120k, so we don't qualify for subsidies in Texas. I don't think we could afford our mortgage if I had to pay for health insurance; $800/month is 8 self-pay doctor visits a month. If I have a catastrophic health event, it makes more sense for me to just declare bankruptcy than it would be to be delinquent on other payments.”

Political fallout is building ahead of the midterms

The survey also captured how the cost increases are shaping political attitudes heading into the 2026 midterm elections.

Among returning enrollees who reported higher costs, seven in 10 (70%) blamed health insurance companies “a lot” for the increase. Approximately half placed blame on congressional Republicans (54%), President Donald Trump (53%) or pharmaceutical companies (52%). A third (34%) blamed congressional Democrats.

KFF noted, however, that while enrollees perceive insurers as a primary driver of their cost increases, policy analysis attributes the main cause to Congress’s decision not to extend the tax credits.

The partisan breakdown is largely predictable, but there are cracks. Among independents with Marketplace coverage, 56% said congressional Republicans and 58% said Trump deserve "a lot" of blame, compared with 28% who said the same about congressional Democrats. And even among Republicans and Republican-leaning independents who support the Make America Great Again movement, a majority (54%) said Congress did the wrong thing by letting the credits expire.

Three-fourths of Marketplace enrollees who are registered to vote said health care costs would affect their decision to vote (73%) and which party's candidate they support (74%) in the midterms. Democrats were more than twice as likely as Republicans to say costs would have a "major impact" on their vote (67% vs. 27%).

What’s next?

The immediate concern is the grace period. Marketplace enrollees who receive tax credits and have not yet paid their premiums generally have until the end of March before their coverage is retroactively terminated. The survey found that 4% of returning enrollees had yet to make their first 2026 premium payment.

How many people ultimately lose coverage through nonpayment or inability to afford premiums remains to be seen. But, with 17% of returning enrollees expressing doubt about their ability to pay all year, the attrition is unlikely to stop at open enrollment.

The broader trajectory is also clear, as federal health care policy is simultaneously shrinking ACA subsidies, tightening Medicaid eligibility and adding administrative barriers to enrollment. For physicians in primary care and private practice, the practical implications include shifting payer mixes, rising uncompensated care and a growing population of patients who delay or forgo care because they simply cannot afford it.

As Altman put it in a KFF briefing last summer regarding the impact of the OBBBA on health care, "It isn't one story, it's many stories about different groups. It's a big and complex story, and it isn't just about how many uninsured. It's about how health care becomes even more unaffordable for a lot of people."