Nationwide Affordable Care Act Marketplace enrollment fell to 19.2 million people in February 2026 following the expiration of the enhanced premium tax credits at the end of 2025. While overall coverage dropped 12% from 2025, enrollment shifts varied across congressional districts.
In Plain English: The Clinical Takeaway
- Financial Toxicity of Care: When monthly premiums jump 58% and deductibles rise by about $1,000 per person, patients face increased costs.
- Geographic Disparities in Access: Populations residing in states that have not expanded Medicaid rely on subsidized Marketplace plans to manage conditions.
- Coverage Continuity Risks: A KFF survey of 2025 Marketplace enrollees revealed that 1 in 10 respondents became uninsured in early 2026.
Regional Disparities and Congressional District Concentration
Marketplace enrollment changes were not distributed evenly across the United States. In certain regions, particularly across the South, a sizable portion of the local populace depends on federally facilitated or state-based exchanges. There are 21 congressional districts situated solely within Florida that boast over 100,000 Marketplace participants, which encompasses the nation’s top 11 districts for enrollment volume. According to data provided by the Centers for Medicare and Medicaid Services (CMS) and state-based exchanges, enrollment reaches up to 31% of the population in Florida’s 27th Congressional District (FL-27), 30% in FL-28, 29% in FL-24, and 28% in FL-26. Districts in Texas, Georgia, and Utah also feature concentrations where Marketplace enrollment accounts for at least 10% of the total local population.
Conversely, states with broader public coverage options maintain lower figures. Twenty-four of the 25 congressional districts with the lowest estimated Marketplace enrollment are located in New York, each recording fewer than 10,000 enrollees. Minnesota, Oregon, Kentucky, and Hawaii similarly demonstrate low ACA Marketplace enrollment, with less than 3% of the population enrolled in an ACA plan across the majority of their districts. These five states have expanded Medicaid eligibility up to 138% of the federal poverty line (FPL), while New York, Minnesota, and Oregon implement Basic Health Plans to cover low-income residents.
| State | State Population Share Enrolled |
|---|---|
| Florida | 16% |
| Georgia | 11% |
| Texas | 10% |
| Utah | 10% |
| New York | 1% |
Political Distribution of Enrollment Declines
The expiration of enhanced premium tax credits at the end of 2025 disrupted coverage security, though the decline hit Republican-held districts harder. Most ACA Marketplace enrollees, 55%, reside in a congressional district held by a Republican representative, a proportion roughly equivalent to Republicans’ share of House seats. However, Republican districts accounted for 67% of the total enrollment decline observed between 2025 and 2026.
Among the top 10 Republican districts with the highest number of Marketplace enrollees, Florida and Texas dominate the metrics. FL-27 leads with 249,000 enrollees, followed by FL-28 with 238,000, FL-26 with 223,000, FL-11 with 139,000, FL-21 with 128,000, FL-18 with 127,000, TX-15 with 124,000, FL-19 with 121,000, FL-05 with 109,000, and FL-12 with 105,000. In a similar fashion, high-volume enrollment areas represented by Democrats consist of FL-24 (229,000), FL-25 (192,000), FL-20 (183,000), FL-10 (182,000), FL-09 (172,000), FL-22 (155,000), FL-23 (145,000), TX-28 (132,000), FL-14 (116,000), and GA-13 (109,000).
Contraindications & When to Consult a Doctor
Methodological estimates for this analysis utilized county-level effectuated enrollment from state-based exchanges alongside CMS Open Enrollment Period Public Use Files, allocating counts based on the 2020 decennial census distribution via block equivalency files for the 120th Congress.
References
- Centers for Medicare and Medicaid Services (CMS). Open Enrollment Period (OEP) County-Level Public Use File (PUF) and Monthly Effectuated Enrollment Data.
- Kaiser Family Foundation (KFF). Survey of 2025 Marketplace Enrollees.
- U.S. Census Bureau. Vintage 2025 Population Estimates Program and American Community Survey 1-Year Estimates.
