Breaking: HHS report admits Trump/GOP policy had already thrown 2.6M off the ACA cliff as of FEBRUARY

Some Guy, January 2026:

So, what does this mean for monthly effectuated enrollment this year? Well, it's pretty safe to say that it's not going to look anything like the ePTC years [ie, 2021 - 2025]; in fact, at least a half-dozen state-based ACA exchanges have posted press releases warning that they're already seeing record levels of plan cancellations.

Instead, it seems pretty clear that the pattern is much more likely to resemble one of the NON-ePTC years. Here's what it would look like if effectuations in 2026 follow the exact path of those years...

...Depending on which year it mimics, average 2026 effectuations will range somewhere between 18.2 million - 20.9 million per month. If so, this would mean anywhere from 1.4 - 4.1 million fewer exchange enrollees than 2025.

...Of course it's also conceivable that the actual 2026 pattern won't resemble any of these; it could be higher or lower. Personally, I suspect it will be lower, with a steeper drop-off in the first quarter of the year, followed by more gradual attrition as the rest of 2026 passes by.

Paige Cunningham, NOTUS, May 12, 2026:

More than one in five people who enrolled in health insurance through HealthCare.gov during open enrollment and in the weeks immediately following were dropped from coverage for failing to pay their first month’s premium, according to internal Centers for Medicare and Medicaid Services, or CMS, documents obtained by NOTUS that haven’t been made public.

The roughly 21% decline in enrollment in the 30 states using the federal marketplace is significantly higher than the rate of last year, when 12% of enrollees dropped off over the same time frame.

...This year also saw fewer sign-ups to begin with, leaving total ACA enrollment at around 19 million people, around 3 million fewer than one year ago, according to CMS documents.

...Nationally, ACA enrollment has declined somewhat less — around 17% percent — between February and April. That’s because the 20 states running their own marketplaces were able to retain far more customers, losing 8% since the beginning of the year, according to the CMS documents.

I wrote about this at the time, noting that Cunningham's story didn't include state-level details, nor did it include effectuated data for January, February or March. However, i was able to use the national numbers she did provide to put together the main takeaway, which was that effectuated enrollment had dropped from ~22.2 million as of April 2025 to ~19.2 million as of April 2026...a net drop of 3.0 million people year over year.

Well, today, the Office for the Assistant Secretary for Planning & Evaluation (ASPE) division of the HHS Dept. published the actual report...and while it’s technically not quite as bad on the surface, it’s actually much, much worse than I had previously thought, as I’ll explain below.

From the summary:

• Due to temporary legislative changes and regulatory approaches that reduced program integrity safeguards, from 2021 to 2024, the ACA Exchanges saw unprecedented enrollment growth, nearly half of which was suspected to be improper, phantom or fraudulent.
• Enrollment that is improper or fraudulent is enrollment by individuals misstating their income to gain access to free plans. Phantom enrollees are unknowingly enrolled in free plans by brokers or auto enrolled. By our estimate, improper, phantom and fraudulent enrollment peaked at 5.6 million people in 2025.
• In 2025, the Trump Administration issued the Marketplace Integrity and Affordability Rule, which took significant measures to ensure those receiving subsidies were actually eligible for those subsidies.
• Currently, an estimated 19.2 million Americans are enrolled in ACA Exchange plans. This figure is higher than every year prior to 2024.
• 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. Trump Administration program integrity efforts stopped about 1.5 million enrollees from receiving subsidies they did not qualify for and ended or blocked another 1.4 million through February 2026, for a total of 2.9 million people who had previously been improperly receiving subsidies they did not qualify for.
• Unfortunately, improper, phantom, or fraudulent enrollment persists. Recent experience during and after the 2026 Open Enrollment Period strongly suggests ongoing and persistent fraud, waste, and abuse in the system. We estimate 2.6 million improper and phantom enrollments remain, including over 1 million enrollments without a social security number.
• The Trump Administration remains committed to aggressively rooting out waste, fraud, abuse, and corruption to protect Americans from unscrupulous brokers using their information to secure payments from the federal government and safeguard the program’s long-term stability for those that depend on it.

I'm going to completely ignore all of the stuff about "waste, fraud, abuse & corruption" for the moment (I'll write a whole separate post about the rest of the report soon) and look purely at the key number: "Currently 19.2 million Americans are enrolled in ACA exchange plans."

The problem with this is the the word "currently." This report was published in late June 2026...but the NOTUS story suggested that it referred to data as of April 2026, which would make sense since a) it was published in May and b) April data would be after the 90-day non-payment grace period had expired.

HOWEVER, when you actually read the report itself, it specifically states:

As of February 2026, an estimated 19.2 million individuals are enrolled in ACA Exchange plans.

Holy crap. February, not April. That's the part that the NOTUS story got wrong.

Why is this such a big deal? Because it means that net 2026 effectuated enrollment had already dropped off much more than I thought.

According to the official CMS Public Use Files, effectuated ACA exchange enrollment as of February 2025 was exactly 21,830,909 people.

If it was down to 19.2 million as of February 2026, that means a net year over year effectuated drop of 2.63 million enrollees well before that 90-day grace period for non-payment would expire on April 1st.

That's a 12.1% net year over year drop in enrollment as of February...which has almost certainly grown substantially higher since then.

Here's what this looks like visually, with the actual effectuated enrollment data for every month from 2019 - 2025. The dotted lines project what enrollment would look like for the remainder of 2026 assuming it follows the 2025 pattern or the 2019 pattern (that was the last pre-COVID year which also didn't include the improved subsidies).

I'm pretty sure the post-February pattern is a lot more likely to follow 2019 than 2025...and more likely still to continue to drop even further as the rest of the year plays out.

The evidence of that is pretty clear based on the limited state-level data I've acquired so far:

• Arkansas: OEP down 3.8%; May effectuations down 5.3%
• California: OEP down 2.6%; February effectuations down 8.5%
• Colorado: OEP down 1.9%; March effectuations down 6.1%
• Georgia: OEP down 12.3%; April effectuations down 28.1%
• Illinois: OEP down 3.7%; May effectuations down 12.4%
• Maryland: OEP up 3.4%; April effectuations down 6.3%
• Massachusetts: OEP up 3.7%; April effectuations down 4.3%
• Minnesota: OEP down 8.1%; February effectuations down 8.6%
• Nevada: OEP down 5.8%; May effectuations down 11.1%
• New Jersey: OEP down 0.8%; April effectuations down 11.6%
• New Mexico: OEP up 18.1%; May effectuations up 5.6%
• New York: OEP down 4.9%; May effectuations down 8.7%
• Pennsylvania: OEP up 1%; May effectuations down 5.2%
• Vermont: OEP down 7.7%; April effectuations down 11.5%
• Washington: OEP down 5.9%; February effectuations down 15.7%

Anyway, as I said, I'll be posting a longer piece about the rest of the ASPE report (which focuses heavily on supposedly rampant "waste, fraud & abuse" of course) next week.