NEW YORK (AP) — Nationwide enrollment in the Affordable Care Act health insurance marketplace could plummet by nearly 5 million people this year, shrinking the number of participants in the program by more than 20%, according to a new analysis from the healthcare research nonprofit KFF.

Those who remain covered are also paying more for healthcare than they used to, the group found, with the average enrollee's deductible growing by more than $1,000 and the average monthly premium payment rising by $65.

"No matter how you slice it, people are paying more," said Cynthia Cox, a vice president of KFF who co-authored the report.

The projected drop-off, much starker than initial federal data suggested, reveals how rising health costs, in part due to the Jan. 1 expiration of subsidies that had helped the vast majority of enrollees pay for their coverage, are forcing Americans to make tough decisions mid-year about whether to keep or go without health coverage.

It's an issue that could play heavily in this year's midterm elections, where voter concerns about economic stressors have taken top billing in many of the most competitive races around the nation.

Enrollment is declining nationwide

ACA enrollment could fall from 22.3 million Americans in 2025 to around 17.5 million this year, according to KFF's report, which relied on federal and state data as well as findings from the actuarial firm Wakely Consulting Group.

That's a significant drop for the government's flagship subsidized health insurance program for working-age Americans who don't qualify for Medicaid. In recent years, ACA plans have become a popular choice for gig workers, farmers, ranchers, hairstylists and others who don't get their health coverage through an employer.

Part of the reason for such a large decline is that many Americans were auto-renewed in their plans from last year, Cox said. In many cases, those plans are now far more expensive because of expired subsidies and other market factors.

When people become unable to pay the monthly fees partway through the year, they lose the coverage, Cox said.

A higher proportion of middle-income Americans dropped coverage compared to other groups, the report found. That group makes too much money to qualify for the remaining subsidies in the program that are reserved for low-income enrollees. But they don't make enough to comfortably afford their health coverage without the COVID-era enhanced subsidies that are now expired.

Drops in ACA sign-ups were seen across most states, KFF found, though states that had their own exchanges retained a larger percentage of enrollees than states that relied on the federal marketplace.

The Trump administration has maintained that federal efforts to root out fraud in the ACA program are responsible for most of this year's drop-offs. The Centers for Medicare and Medicaid Services, whose final 2026 enrollment data is not yet public, didn't immediately respond to a request for comment on KFF's report.

High costs for those still in the marketplace

Last year, anticipating the expiration of the COVID-era subsidies that had boosted enrollment and offset costs for ACA users for the past four years, KFF had projected that premium payments would more than double in 2026.

As it turned out, premium payments jumped by a more modest 58% on average, the new analysis found. That was partially because many people downgraded to lower-premium, higher-deductible plans that will cost them more money only if they use the coverage, KFF's report said.

"People are trying to hang on to their health insurance coverage any way they can, even if that means they have a deductible of $7,000," Cox said.

Others kept the same plans and are struggling to manage higher monthly costs. Caitlin McElroy, 38, in Orlando, Florida, saw her premium payment soar from $32 to $89 per month, but she needs the coverage to manage her Crohn's disease and her mental health.

On her modest salary, she makes it work by sacrificing social events, delaying utility payments and cutting fresh produce out of her diet when she can't afford it.

"I try to just cut corners wherever I can," she said in an interview.

The potential good news, Cox said, is that insurers seem to have predicted and already made adjustments for many of the marketplace changes that are playing out.

That could mean future health costs don't have to rise so sharply.

"I'm hopeful that this could be a one-time market correction and that we might not need to see such a high premium spike in the coming year," Cox said.