Enrollment in Affordable Care Act plans fell by nearly 3 million this year to about 19.2 million, following steep premium increases by insurers and the Republican-led Congress’ unwillingness to extend more generous premium subsidies. On average, ACA customers in premium payments this year, a 58% increase from 2025, according to KFF, while their deductibles — the amount consumers must pay annually before insurers pick up their share — have climbed 37% to nearly $3,800 a year.

“These are real people who are now forced to make impossible choices,” said Annalyse Keller, a spokesperson for a large coalition of lobby organizations for the healthcare industry, including insurers and patient advocacy groups.

But a released in June, written mostly by President Donald Trump’s political appointees and allies, asserts that 5.6 million people were fraudulently enrolled in ACA plans in 2025, and that the Trump administration removed 2.9 million of them — the same number as the 2026 drop in enrollment.

There’s little dispute that the ACA suffers from some fraud, as do most government programs. The administration said it has taken actions to tighten the enrollment process to thwart brokers who fraudulently enroll people without their knowledge.

For example, the administration in August 2025 halted a Biden-era initiative that allowed low-income people to sign up for coverage year-round. Regulators 1.5 million people since 2025 for reasons such as not meeting a requirement to file their taxes over two years or being concurrently enrolled in another health program, such as Medicaid, which is not allowed.

But health policy experts say that the administration is overstating the extent of ACA fraud and that the HHS report relies on debatable assumptions, such as that all sign-ups under the year-round enrollment program for low-income people were potentially fraudulent. ACA enrollment fell off a cliff because of escalating prices for insurance plans, policy analysts say, which the administration’s done nothing to stem.

“The top-level claim” that all the decline in enrollment since 2025 is because of improper or fraudulent enrollees leaving the market “is not remotely credible,” said , a senior fellow at the Brookings Institution. “We know that lots of people have seen higher premiums, and there’s really good evidence that when premiums go up, people drop coverage.”

Healthcare costs are a big concern for voters ahead of November’s midterm elections, and both Democrats and Republicans are trying to spin the issue to their advantage. Democrats argue more needs to be done to make insurance less expensive for consumers, while Republicans are trying to focus on the need to save taxpayer dollars from fraud.

found that voters trust Democrats over Republicans to address healthcare costs (37% vs. 26%). The poll also found, though, that 55% of Republican voters consider it extremely important for candidates to address healthcare fraud, more than any other issue, showing that the White House’s effort to shift focus from costs has had some success with its own supporters.

But Jonathan Oberlander, a professor of health policy and management at the University of North Carolina, questioned whether the fraud narrative will hold up as voters continue to struggle with rising costs.

“It will be cold comfort to the very real persons who could no longer afford coverage and dropped their plans,” he said in an email to Ñî¹óåú´«Ã½Ò•îl Health News.

How We Got Here

Under President Joe Biden, Congress that included more generous tax subsidies for people enrolled in Obamacare, starting in 2021. Those enhanced subsidies lowered premium payments, for a large enough tax credit to reduce their monthly payment to zero. The Biden-era law also allowed wealthier households to get assistance.

ACA coverage essentially doubled, from just over 11 million Americans in 2021 to more than 22 million in 2025, according to the HHS report.

Republicans and conservative groups argue that the growth wasn’t driven only by people newly enrolling because of lower premiums. Instead, they say, the enhanced subsidies, along with other Biden-era policies — including easing income verification requirements for some enrollees — invited fraud. Unscrupulous, commission-seeking insurance brokers found it easier to sign people up for coverage, often without their knowledge, while ordinary consumers could more easily fudge their income and qualify for the largest subsidy possible.

The conservative Paragon Health Institute’s president, Brian Blase, wrote that the HHS report’s conclusion on the scope of improper enrollment is likely an undercount. He remains unconvinced by the arguments that rising premiums are to blame for the sharp drop in ACA enrollment, saying subsidies remain generous for many people.

The Administration’s Current Targets

The debate will continue as more enrollment data emerges from the federal marketplace and the exchanges run by states. Some policy experts — including the consulting group Wakely — expect the year to end with the number of ACA policyholders down by .

Trump’s regulators will likely connect further drops with anti-fraud efforts. The HHS report alleges there are potentially millions more who remain improperly enrolled. The report’s authors noted that some of the administration’s anti-fraud proposals have been blocked by court rulings.

HHS released June 27, HHS Secretary Robert F. Kennedy Jr. pats Mehmet Oz, the head of the Centers for Medicare & Medicaid Services, on the back for the number of canceled ACA plans so far. Oz threatens potential ACA hucksters: “Don’t walk away from us, run! Because we are going to find you.”

In an email responding to Ñî¹óåú´«Ã½Ò•îl Health News’ questions, CMS spokesperson Christopher Krepich said his agency this summer will block ACA applications made by brokers that lack a Social Security number. By open enrollment this fall, CMS plans to require more identify-proofing when brokers enroll people and will limit a broker’s access to accounts until that person “has been authorized by the consumer to work on their behalf.”

How some suspicious enrollments will be removed is spelled out in emails sent in June to insurance carriers and obtained by Ñî¹óåú´«Ã½Ò•îl Health News.

CMS told insurers that the agency will send them files for ACA accounts it believes are potentially unauthorized. Each flagged consumer account will have used a sales broker to enroll, be in a zero-premium plan, and lack a Social Security or an immigration documentation number — which Kennedy said in the video is a glaring sign of fraud.

Insurers must try to contact the enrollees to verify that they signed up for coverage. After 60 days, insurers must report policies they were unable to verify to CMS, which will cancel them.

Krepich wrote that carriers are cooperating with efforts to investigate accounts with missing or unverified information.

Policy experts, including Fiedler, note that the absence of a Social Security number doesn’t automatically prove fraud. While it could indicate a fake enrollee, a missing Social Security number might also be a simple oversight by the consumer or their broker, for example, or a newborn added to a parent’s account at birth, before they’ve received a number.

“That the administration put it in a report and did not summarily terminate these enrollments suggests they believe there is some mix of different circumstances,” Fiedler said.

The administration report singles out another segment of enrollments as suspicious: very low-income, subsidy-eligible people who shifted to plans that carry no monthly premium, suggesting “fraudulent agents and brokers are moving them to keep gaining commissions and avoid detection.” The report also cites ACA enrollees who file no medical claims as suspicious.

Policy experts question the assumptions behind those concerns.

Younger or lower-income people use healthcare less often, for example, which can explain why they may make no claims — particularly when they must first spend thousands of dollars out-of-pocket to meet high deductibles.

And very low-income people may switch to plans with higher deductibles in exchange for making no premium payment because they struggle to come up with the $50 or $80 monthly share that other plans might require.

“People are hurting for money,” said Florida insurance agent Jason Fine. “I literally have people who can’t afford to pay $15. I would not immediately assume that a person who went from a silver plan to a bronze plan, that it’s fraud,” referring to two types of ACA plans.

Fine said the administration needs to focus on better enforcement of existing rules, saying he has reported to regulators dozens of unscrupulous agents who have switched clients without authorization, yet none were barred from selling ACA policies.

He and other agents continue to push for adding multifactor identification, as banks and other financial institutions use, to the federal ACA marketplace. Some states that run their own exchanges have two-factor authentication or other types of ID verification and have not reported problems with unauthorized switching.

CMS — under both Biden and Trump — has not added two-factor authentication to the federal marketplace, healthcare.gov.

Rep. Glenn Grothman (R-Wis.) to require it in June, but its prospects are murky.

“It will help reduce fraud,” said Ronnell Nolan, who leads Health Agents for America, a lobbying group that has long urged CMS to add the feature. Grothman’s legislation, she said, might “encourage CMS to do it themselves.”

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Ñî¹óåú´«Ã½Ò•îl Health News chief Washington correspondent Julie Rovner discussed the Fauci hearing on WBUR’s Here & Now on July 29. Rovner also discussed exceptional Affordable Care Act enrollment in New Mexico on KJZZ’s The Show on July 29.

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The officials, all Democrats, are running at a time when the Trump administration is reducing government funding for scientific research, restricting access to some vaccines, and making it more difficult for some Americans to obtain health insurance.

Shaughnessy Naughton, president of 3.14 Action, a political action committee that recruits Democratic candidates with science and health backgrounds, said it is unusual to see so many public health leaders running for office.

“But it’s not surprising given the moment we are living in, with an arsonist running HHS working to undermine the vaccine schedule and public health at large,” she said.

Health and Human Services Secretary Robert F. Kennedy Jr. is a longtime anti-vaccine activist who disparaged public health measures implemented during the pandemic, going as far as calling the covid vaccine the “.”

Neither HHS nor the White House responded to requests for comment.

Several of the candidates benefit from name recognition built during the covid pandemic, political science scholars say, when daily news briefings from local health officials became must-see-TV for many citizens sheltering in place from the novel virus. But that cuts two ways.

While many Americans regarded public health officials as offering prudent advice and a steady voice, others criticized them for pushing school closures, mask mandates, and new, quickly created vaccines. The attacks have escalated under President Donald Trump, with Republicans targeting pandemic-era public health leaders such as Anthony Fauci and a former Fauci adviser even facing .

National polls show healthcare is for many voters this year, with Democrats most worried about costs and Republicans about fraud. But that’s no guarantee of victory. Nirav Shah, an epidemiologist who led Maine’s top public health agency through the pandemic, lost a narrow Democratic primary in the state governor’s race in June.

Here are some of the public health officials on the ballot this year:

Xavier Becerra, Running for Governor in California

Becerra, who served as HHS secretary under President Joe Biden, is the highest-ranking former health official running this cycle. He won a crowded and expensive open primary and now faces Republican Steve Hilton, a British-born former Fox News host, in the general election.

Mark Peterson, a public policy professor at the UCLA Luskin School of Public Affairs, said with the pandemic in the rearview mirror, any judgment voters may have about the federal government’s response is more likely to reflect on Biden rather than Becerra, who has no medical background and maintained a low profile as HHS secretary.

Leading the nation’s health department as the pandemic lingered, Becerra focused more on expanding access to the Affordable Care Act and Medicaid, overseeing record numbers of people enrolled in the publicly financed programs during his tenure. He did face criticism over the processing and placement of a massive influx of migrant children at the U.S.-Mexico border, as well as his agency’s response to a baby formula shortage brought on, in part, by major product recalls.

Becerra has said he now wants to be California’s “healthcare governor,” a mantle outgoing Gov. Gavin Newsom tried to claim upon taking office in 2019.

Becerra’s campaign did not respond to a request for comment.

Before becoming HHS secretary, Becerra served as California’s attorney general and sued the first Trump administration more than 100 times, leading a coalition of states against GOP efforts to gut the ACA. He also started a unit in his office focused solely on healthcare. During Becerra’s tenure, his office reached a $575 million antitrust settlement with the California hospital system Sutter Health, pursued pharmaceutical companies that delayed generic drugs, and helped block a Trump administration rule that let employers choose whether to cover .

Voters often regard decades of experience in government as a negative, Peterson said. But for the job of running the nation’s most populous state and the world’s fourth-largest economy, he added, “I think there are a lot of people out there who would like to have somebody who actually has run a big enterprise.”

In , Becerra has said California should maintain state-funded Medicaid coverage for immigrants without legal status. He is also a longtime supporter of implementing single-payer healthcare, though in recent interviews he has said it needs to be addressed at the federal level.

Amy Acton, Running for Governor in Ohio

Acton ran Ohio’s health department from February 2019 to June 2020.

During the first months of the pandemic, Acton appeared at daily news conferences with the state’s Republican governor, Mike DeWine, that were jokingly dubbed “.” She earned fans with her calm and positive demeanor while explaining her approach to keeping covid at bay.

But she also attracted critics with her recommendations to stay at home, mask up, and shut down some businesses to curb the virus’ spread. Protesters even showed up at her home.

Acton’s Republican opponent in the governor’s race, Vivek Ramaswamy, has labeled her “Dr. Lockdown” on social media. His criticism of her role in shutting down businesses could prove effective with the economy at the top of many people’s minds, said Christopher Devine, a University of Dayton political science professor.

“It’s a double-edged sword, because she also really upset some people,” Devine said of Acton’s time as the health director during the pandemic.

He said that is a tricky attack for Ramaswamy to pursue, though, because DeWine — still the sitting governor and a popular conservative figure — endorsed the covid measures Acton recommended, granting her emergency powers to sign the orders, and has since said he takes all responsibility for those actions.

For her part, Acton has done little on the campaign trail to highlight her time as the state’s public health director. Instead, she has focused more on healthcare affordability, highlighting the Trump-led cuts to Medicaid and the scaled-back subsidies for ACA plans that have resulted in dropping coverage in the state.

“I hear from families across Ohio that healthcare costs are rising and they just can’t keep up,” Acton said in an emailed statement. “That’s why I will fight to protect and expand access, reduce the price of prescription drugs, forgive medical debt holding Ohioans back, and lower premiums.”

Abdul El-Sayed, Running for U.S. Senate in Michigan

El-Sayed — who ran the health departments in the city of Detroit and Wayne County, Michigan — is one of two leading Democratic candidates for Senate. The primary is Aug. 4.

El-Sayed, a progressive, is facing off against Haley Stevens, a four-term congresswoman. They are vying to run against Republican nominee Mike Rogers, a former congressman, for the Senate seat held by retiring Democrat Gary Peters.

From 2015 to 2017, El-Sayed ran the Detroit Health Department, which and privatized as part of the city’s 2013 bankruptcy. In his role, he led efforts to test Detroit schools for lead in the wake of the Flint water crisis and provide free eyeglasses to children in public schools.

From 2022 until 2025, he ran the health department in Wayne County, the state’s most populous county, which includes Detroit. In that job, he initiated a program to retire medical debt for thousands of residents and make naloxone available in public areas to reverse the effects of opioid overdoses.

In an interview with Ñî¹óåú´«Ã½Ò•îl Health News, El-Sayed said his public health experience helped him become an effective communicator and challenge corporations and the role they play in healthcare.

“Politics have become overrun by big money and corporations, and my training and background in public health has taught me to think about that and push back against it,” he said.

El-Sayed, who did not practice medicine after completing his residency and is not licensed to do so, has faced criticism from some in his party for calling himself a doctor.  

El-Sayed, who has endorsements from Sen. Bernie Sanders (I-Vt.) and U.S. Rep. Alexandria Ocasio-Cortez (D-N.Y.), supports “Medicare for All,” a policy favored by many progressives that would make more people eligible for the federal health program for people who are 65 and older or disabled.

David Dulio, a professor of political science at Oakland University in Rochester, Michigan, said that the broader economy, Trump’s tariffs, and trade are eclipsing healthcare this year as top concerns for voters in the state. But he added that “progressive stances such as Medicare for All are attractive in the Democratic primary electorate.”

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Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Julie Appleby discussed the affordability of Affordable Care Act health insurance plans on Connecticut Public’s The Wheelhouse on July 22.

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Céline Gounder, Ñî¹óåú´«Ã½Ò•îl Health News’ editor-at-large for public health, discussed tick bites on CBS’ CBS Mornings on July 20. She also discussed wildfire smoke and severe heat on CBS’ The Daily Report on July 16.

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Céline Gounder, Ñî¹óåú´«Ã½Ò•îl Health News’ editor-at-large for public health, discussed the Department of Health and Human Services’ plan to offer compensation for automatic covid vaccine injuries and the drop in enrollment in Affordable Care Act health plans on CBS’ The Takeout With Major Garrett on July 10 and 9, respectively.

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In preliminary filings with state regulators, insurers are seeking a median rate increase of 14% for 2027, according to in 16 states and the District of Columbia by the Peterson-Ñî¹óåú´«Ã½Ò•îl Health System Tracker.

If those rates are ultimately approved, it would be the second-highest increase since 2018.

That would be a “triple whammy” for consumers, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at KFF, because they have already had to pay higher premiums in 2026 and saw the expiration of more generous tax credits to offset their premiums at the end of last year.

President Joe Biden sought to bolster the program known as Obamacare by enacting more generous tax subsidies, driving down out-of-pocket costs for consumers and increasing enrollment to more than 20 million Americans. But under President Donald Trump, Republicans have sought to scale back taxpayer support for ACA coverage, allowing the Biden-era enhanced subsidies to expire.

As of February, ACA enrollment had fallen by about 3 million people compared with the same time last year. While Cox and other policy experts say that’s because increased costs for the plans drove out people who feel they can get by without insurance, the Trump administration asserts that much of the enrollment growth under Biden .

The main factor driving proposed premium increases for 2027, as in most years, is the rising cost and use of medical care.

There’s growing demand for costly specialty medications and for the weight loss drugs known as GLP-1s, the Peterson-KFF report notes.

But the report also said that about 4 percentage points’ worth of the premium increases insurers proposed are due to lasting effects of the expiration of enhanced subsidies. Insurers expect that with young and healthy people leaving the program rather than paying higher premiums, their remaining customers will be older, sicker, and therefore costlier on average.

 “It’s likely that the people who dropped their coverage were also the healthier people, because sicker people were probably going to try to make it work however they could, to stretch their budget to keep their health insurance,” said Cox, of KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

In their rate filings, some insurers also said they had to raise premiums partly because of policy changes by the Trump administration that are expected to make it harder for some people to enroll.

Together with the expiration of the larger subsidies, the new rules “account for 12.7% of the requested rate change,” the insurer UnitedHealthcare wrote in its rate filing with New York state, according to the Peterson-KFF report.

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Cohen is a 38-year-old Las Vegas resident with autism and has dual enrollment in Medicaid and Medicare. He said he’s very concerned that he could lose his Medicaid coverage once work requirements and more frequent eligibility checks take effect in January, under congressional Republicans’ One Big Beautiful Bill Act.

“When you’re going to some providers, notably mental health, once a month, or in the case of one provider, a couple of times a week, those copays quickly add up,” Cohen said.

Republican Gov. Joe Lombardo is running for reelection against Democratic state Attorney General Aaron Ford in one of to be decided in November. Lombardo has , but healthcare policy changes made by the Trump administration are working against him with voters like Cohen in the swing state.

Those changes include Medicaid funding cuts that are expected to strain state budgets, along with new work requirement and eligibility rules for Medicaid and the Supplemental Nutrition Assistance Program, which provides food assistance for low-income families. The changes are expected to increase the number of people without health insurance nationwide by an estimated and decrease the number of people who receive SNAP by from 2025 to 2034.

People across the U.S. have also been feeling the pinch of rising health insurance premiums since Congress allowed enhanced Affordable Care Act subsidies to expire at the end of last year. Many who purchase health plans on the ACA marketplace have chosen less expensive plans with less coverage or are going without insurance altogether.

These changes will have a significant impact in Nevada, where tourism, hospitality, and gaming are cornerstones of the state’s economy. Nearly are self-employed, independent contractors, or freelancers without employer-sponsored health insurance benefits. Many purchase insurance through the state’s ACA health exchange, in enrollment this year after a record 110,000 people signed up for 2025.

Even before the federal changes, Nevada’s 11.4% uninsurance rate was already the , according to data from 2024. A in May that an estimated 70,000 Nevadans could lose their Medicaid coverage under the new rules. Around in the state lost access to SNAP in May.

“This is going to come down to an affordability election, and that’s going to hurt the Republicans,” said , a professor in the political science department at the University of Nevada-Las Vegas.

In a national this year, two-thirds of respondents said they were worried about affording healthcare, more than said the same about food and groceries, housing, or gas. And more than half said their healthcare costs had increased in the past year. KFF is a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

While most respondents said that healthcare costs will influence whom they vote for in November, the issue was more pressing among Democrats and independents.

Competitive gubernatorial races are also underway in Arizona, Georgia, Iowa, Michigan, and Wisconsin, with all those races .

The Democratic Party has the edge on healthcare issues over Republicans, but about 3 in 10 voters reported that they don’t trust either party, noted Liz Hamel, a senior vice president and the director of public opinion and survey research at KFF.

“It’s not an overwhelming advantage,” she said.

Not Your Textbook Republican Governor

Lombardo’s campaign his support for a children’s hospital set to be built in Las Vegas; his consolidation of the state’s Medicaid program, ACA marketplace, and public employee benefits program into a single agency; and the expansion of the number of community behavioral health centers in the state during his term.

Before running for governor and unseating Democrat Steve Sisolak in 2022, Lombardo served eight years as sheriff in Nevada’s Clark County. Before that he spent with the Las Vegas Metropolitan Police Department.

Lombardo has taken healthcare stances in his first term that diverge from the typical Republican playbook. For example, that he would oppose a national abortion ban, and in 2023 he prohibiting state agencies from cooperating with other states seeking to prosecute people for traveling to Nevada to get an abortion.

The governor also signed bills into law in 2023 that from engaging in gender discrimination and to ensure greater protections for transgender and nonbinary people, including setting standards for medical care and mental health treatment.

More recently, Lombardo has taken actions more aligned with the Make America Great Again movement. In 2025, he that would have created protections for clinicians who provide gender-affirming care. This year, he to ban transgender athletes from girls’ and women’s sports.

Lombardo’s campaign declined to make the governor available for an interview for this report. In a with Jon Ralston, CEO of the nonprofit news outlet The Nevada Independent, Lombardo said he was surprised during his first term as governor by how “complicated” and “encompassing” healthcare is, and by the “cost of it.”

“Government seems to complicate some of those bigger processes more often than not,” Lombardo said, “but in this case, they’re instrumental in the success or failure of healthcare and how people suffer as a result of bad decisions.”

His opponent, Ford, began his political career as a Nevada state senator and became the state’s first Black attorney general in 2019.

Ford has talked about how he raised his eldest son on his own while attending Texas A&M University. He said he relied on public benefits such as Section 8 housing, Medicaid, food stamps, and the Women, Infants and Children program to provide for them.

He said because of those experiences, his thoughts go to the Nevadans expected to lose Medicaid coverage whenever he hears a reference to the “Big Beautiful Bill.”

“It hits me differently,” Ford said.

His campaign’s calls for lowering prescription drug costs, boosting awareness of the state’s public-option health plans that debuted this year, and canceling medical debt.

A Referendum on Trump?

Most voters who responded to KFF’s poll said they have little or no confidence in how the Trump administration is addressing the cost of living.

“It seems like, if anything, the Trump administration’s approach is not going to help Republicans in the midterms,” Hamel said. But, she added, “November is many months away. A lot of things could change.”

Lombardo appears to be distancing himself from the president amid soaring gas prices and broader affordability issues.

When Trump visited Las Vegas in April, Lombardo didn’t attend the event. The governor later that he would be meeting with the president during his visit, but they spoke only by phone. Damore said he doesn’t think it was an accident that Lombardo didn’t appear with the president publicly.

“Lombardo has done a nice job trying to thread the needle between himself and Trump,” he said.

But Ford has an easier road ahead when it comes to campaigning for healthcare issues, Damore said.

“He just kind of has to say, ‘I’ll do better,’ and point the finger at Trump and say, ‘Where is Lombardo fighting this kind of stuff?’” Damore said. “That’s a pretty easy campaign for him.”

Partisan Nevada voters are nearly evenly split between the two parties, but the majority are registered as nonpartisans, probably because the state’s makes “nonpartisan” the default option for residents who register at the Department of Motor Vehicles. As of last year, voters can no longer choose a party at the DMV, instead needing to fill out paperwork their county election office mails after they register.

Clark County, home to Las Vegas and of , leans Democratic. The next-largest county by population is Washoe County, which is home to Reno and is the in the state. The rest of the state is rural and consistently votes Republican.

But voters in Nevada are fatigued, Damore said, after years of inflation and rising costs since the covid pandemic.

“People are just kind of surly,” he said. “They keep kind of ping-ponging back and forth between the parties. It doesn’t seem to change much.”

Cohen, the Las Vegas voter, is a registered nonpartisan. He said he plans to vote for Ford because he is the candidate who seems most willing to work to protect Medicaid enrollees.

“Sometimes the only way to get something done, to protect it, is to sue,” Cohen said. “I think he’ll bring that background.”

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The measure is unlikely to pass in the Republican-controlled Congress, but Democrats could use the vote against their opponents on the campaign trail.

When the ACA rule was released in May, the Trump administration as a means to combat enrollment fraud, lower premiums for some people, and offer a wider range of insurance plans, including ones with no set network of doctors or hospitals.

But many Democrats warned the changes would hurt consumers already suffering from high healthcare costs as well as higher prices for gas, groceries, and other household needs. Estimates from the administration found the regulation, called a notice of benefit and payment parameters, could cause to lose ACA coverage.

Senate Minority Leader Chuck Schumer and fellow Democratic Sens. Tammy Baldwin of Wisconsin and Ron Wyden of Oregon plan to introduce on Wednesday a to block the rule.

Baldwin told Ñî¹óåú´«Ã½Ò•îl Health News in a statement that the rule is “misguided” and said she was “committed to doing everything she can” to stop Republicans from “kicking Americans off their health care.”

The directive from the Centers for Medicare & Medicaid Services is an annual exercise that sets standards for ACA coverage during the coming year. Some of the changes in the finalized 2027 rule are technical, but many would affect consumers directly.

They include tighter income verification requirements. The rule also stipulates more eligibility checks on people applying outside of the normal annual enrollment period for such reasons as marriage, divorce, or loss of job-based coverage.

ACA plans themselves would look different too. Insurers would be able to offer some plans with 30% higher out-of-pocket limits (the amount consumers may have to pay each year in cost sharing such as copayments and deductibles), with a new ceiling as high as $15,600 for individual coverage or $31,200 for a family plan.

The Democrats’ effort to overturn the rule is the definition of a long shot; it would need a majority of votes in both the House and the Senate. But simply forcing a floor vote is likely to be seen as a win by the minority party.

“What Democrats are trying to do is get Republicans to vote on policies that would be unpopular if they rose to the level of public consciousness,” said Adrianna McIntyre, an assistant professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health. “Democrats want to showcase that they want to change these policies, even if don’t have the votes to accomplish it.”

Congress has authority under the review act — enacted as part of a larger law in 1996 — to overturn rules issued by federal agencies. such disapproval resolutions have passed, hundreds have been introduced, often mainly to draw attention to an issue.

It is one of the few levers a minority party has to force action on the floor of the Senate.

That’s because if only 30 senators sign a discharge petition to send the measure to the floor, the Democrats get a vote, without needing to go through a Republican-controlled committee or hold a hearing. A companion resolution is expected to be introduced in the House on June 17.

And there’s no doubt that Democrats will try to use any floor vote on health costs as a litmus test for Republicans in the November elections.

“Time and again Democrats have used Republican efforts to undermine the ACA to their political advantage in campaigns, and this year will be no different,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

Polls show that the GOP could be vulnerable if Democrats can convince voters their party would do better on health costs, which are a top concern among voters.

, for example, found that 73% of adults see healthcare costs as a very big problem for the country, leading both inflation and the federal budget deficit. KFF’s tracking polls have found healthcare costs to be a top concern, even among Make America Healthy Again supporters allied with President Donald Trump.

At least half of people who identify as MAHA voters say those health costs on their decision to vote and which party they support.

Medical costs in general typically rise faster than inflation, driven by increased hospital and doctor bills and use of drugs, devices, and other healthcare. That leads to higher costs for employers that offer health plans to their workers and for taxpayer-supported programs such as Medicare and Medicaid, as well as higher premiums for insurance plans sold under the ACA. The consultancy PwC projects the cost to treat patients this year will , the highest in nearly two decades.

Higher premiums and lower subsidies also hit many ACA enrollees this year, with about 1.2 million fewer sign-ups than for 2025 as of January.

Costs “are a good Democratic talking point,” said Joseph Antos, a former government health official who is now a senior fellow emeritus at the right-leaning American Enterprise Institute. “Trump was going to solve inflation, and instead, what do we have?”

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But in December, that changed. The Tobiassens decided to cancel their insurance when Rebecca saw the cost of their monthly premiums would jump from $130 to more than $550.

“It makes no sense,” she said. “It’s not worth it anymore.”

The couple own and are the only employees of a small auto shop just west of Appalachian State University in the North Carolina mountains. Rebecca worries about her husband, whose work as a mechanic can be dangerous. A spring once shot a metal ball joint into their garage wall like a gun. A heavy object crushed Ross’ thumb. In 2020, Ross became mostly blind in one eye after repeatedly getting metal shards in it and developing an infection in his cornea.

The Tobiassens are among the Americans who canceled their ACA coverage after Congress allowed enhanced tax credits that helped pay for insurance plans to expire at the end of 2025. The Tobiassens benefited from those tax credits — like expected to drop or be dropped from their coverage as the year progresses, unable to keep up with the higher costs.

Established by the Biden administration’s American Rescue Plan Act during the covid pandemic, the expanded subsidies reduced monthly premiums for many families and prompted a tidal wave of new sign-ups, doubling ACA enrollment to .

The Centers for Medicare & Medicaid Services is expected to on how many people are no longer covered under the ACA, but an , citing Wakely Consulting Group research, showed enrollment could drop from over 22 million at the end of 2025 to as low as 16.5 million in 2026. 

In North Carolina, individual ACA sign-ups for 2026 were down 22% compared with the year before, a greater drop than any other state, amounting to a decrease of more than 213,000 people, . While the Tobiassens’ two teenage daughters remain on Medicaid, Rebecca said the new prices showed that the federal government doesn’t care about families like hers.

“We’ve known that you don’t care about us,” she said, “but you’re making it plain and simple now.”

The couple’s insurance hadn’t helped them cover all their medical needs. When the pain from Ross’ eye infection worsened five years ago, Rebecca insisted he go to a specialist, who told them that fixing the eye through cornea replacement surgery and require Ross to take six months off.

Ross chose a less expensive treatment to kill nerves in the eye instead.

The couple know they’re taking a risk by not being insured. If something were to happen, they could face an enormous medical bill.

Ross, 47, said the blindness in the one eye doesn’t significantly affect his job. He works long hours, sometimes into the night to keep up with demand.

“I try not to think about it too much,” he said. “I just work.”

Uninsured, With No Backup Plan, After Obamacare Became Unaffordable

Rebecca Tobiassen, 44  
Sugar Grove, North Carolina 

Rebecca Tobiassen owns a small auto repair shop with her husband, Ross, in the western North Carolina mountains. She says their family could no longer afford Affordable Care Act insurance after tax credits expired last year and their monthly premiums shot up from $130 to more than $550. They have no immediate plans to sign up for coverage elsewhere and are saving up for out-of-pocket expenses instead. “We just need to be able to afford to get help when we seriously hurt ourselves,” she said of the U.S. healthcare system. 

Katie Alexander oversees volunteers for Pisgah Legal Services, a western North Carolina nonprofit that helps low-income people secure health insurance. Alexander has helped North Carolina and Tennessee residents try to get ACA marketplace plans since Obamacare’s launch. She said she’s never seen anything like this year. 

Nearly 100 Pisgah clients, out of about 700 that Alexander’s team worked with during open enrollment, decided to drop insurance this year, and many others chose cheaper ACA plans with less coverage, Alexander said. 

Alexander said the people who have dropped their coverage include Lyft and Uber drivers. They’re trying to start their own businesses. They are artists and people who can work only part-time, because they’re chronically ill. Some are unable to get insurance through their employers, or they make too much to be on Medicaid.

“Even for folks who don’t have chronic illnesses,” Alexander said, “there’s just this nagging at the back of your mind, kind of constantly, of: ‘Don’t get hurt. Don’t get sick. Because you can’t afford that.’”

ACA premiums and deductibles steadily increased for years starting in 2022, then spiked during the enrollment period for 2026 plans, . The Tobiassens have seen every dip and rise in plan costs since 2014 when the plans launched. They joined immediately and paid about $30 a month, Rebecca Tobiassen said.  

“You actually felt like you were benefiting,” she said.

But through the years as the marketplace became more expensive, the couple made concessions, switching at one point from a silver plan — historically the — to a bronze. The plan mostly provided for the couple’s basic needs.

As they saw their deductibles and premiums rise over more than a decade, Rebecca feared the day would come when they could no longer afford even the cheapest plan.

“Plans are unaffordable, no matter how you cut it,” said , a healthcare policy researcher at the University of Colorado Anschutz School of Medicine. “It’s just who is shouldering the unaffordability.” 

Gidwani and health economist , in a , found that most bronze plans, the cheapest ACA options for many, would be unaffordable without subsidies for the average person using the federal healthcare coverage.

Without subsidies, many families using these plans don’t make enough to afford premiums or deductibles, Gidwani’s research shows.

People who drop health insurance also change what’s known as the “risk pool,” Gidwani said, when a group of people share financial hazards. 

If healthier people drop out of the risk pool, fewer people subsidize the people who get sick, Gidwani said. That means premiums for the people who get sick will increase again in the future, she added.

“That becomes what we call a death spiral,” Gidwani said.

Even if the subsidies hadn’t expired, taxpayers would have borne an estimated over the next decade to cover them, Gidwani’s study noted.

After dropping coverage they’d relied on for 11 years, the Tobiassens have no plans to return to the ACA marketplace. They looked into alternative options through a faith-based healthcare organization but decided to go without.

For now, they don’t have a plan B. They’ve set aside some money for a medical emergency. And if their savings run out, Rebecca Tobiassen said, they have a couple of last resorts to lean on: credit cards or family members.

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When Congress allowed covid-era subsidies for health insurance to expire, California used its own funds to offset the hike in Obamacare premium costs for residents with low incomes.

But the reach has been limited.

As Gov. Gavin Newsom negotiates his last budget with the legislature, the Democrat wants to offer financial help to more than 1 in 4 enrollees in Covered California, the nation’s largest state-run health insurance marketplace. Democratic lawmakers, who hold a supermajority, are still debating the plan.

“My budget proposal would KEEP $0 monthly plans for low-income Californians to help clean up the financial disaster Trump created,” Newsom , where he often chides the president and GOP Congress.

have put up their own funds to keep Affordable Care Act plans affordable and residents insured as the rising cost of healthcare has emerged as a among voters. Newsom’s $300 million proposal would make California’s program among the most generous, but even the nation’s richest state can’t patch a left by the expiration of enhanced subsides at the end of last year.

“The gap between what people can pay in their monthly budget and what health insurance costs is so big that it’s a lot for states to take on,” said , a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. “They’re going to have to figure out how they can finance that.”

New Mexico lawmakers have of the lost federal subsidies with state money. It seems to have worked; New Mexico saw in marketplace enrollment this year, but state analysts that the subsidy program isn’t sustainable.

and , which, like California, tax residents , are also spending hundreds of millions of dollars to try to keep premium payments low. Their hope, healthcare experts say, is to avoid the exodus seen in states such as Georgia that didn’t offer enrollees help.

Since the enhanced subsidies expired, have seen their premium payments increase by $65 a month on average.

Conservatives including have long argued that the subsidy expansion was too generous to high-income enrollees and .

“There are never enough subsidies to make health insurance affordable because subsidies are the problem,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute. “They are causing people to turn a blind eye to fraud and waste and excessive prices because it’s someone else’s money that they’re spending, not their own.”

Helping the Poorest?

People who earn too much to qualify for Medicaid got relief starting in January after Newsom and legislators softened the blow for about 300,000 of the lowest-income enrollees. They offset lost federal premium tax credits for individuals who last year and partially filled the gap for those who earned up to $25,823.

The governor now wants to expand subsidies to those who earn up to $31,920 this year for an individual and $66,000 for a family of four — an estimated 218,000 additional people.

Veronica and William Walter, who live in the San Francisco Bay Area, earn less than $40,000 a year in one of the nation’s most expensive regions. They’re counting on a more generous state healthcare tax credit if they have to pay for health insurance next year.

A car accident two years ago left William temporarily disabled, qualifying the couple for Medi-Cal, the state’s Medicaid program.

Now he’s back at work as a security guard, and Veronica said she’s worried they’ll be kicked off Medi-Cal. She’s even more worried about how they’ll get by with federal premium tax credits not nearly as generous as before.

“Without it, we’re going to be facing worse problems than we have now,” she said. Under Newsom’s proposal, Veronica and others in the highest eligible income bracket could receive an average monthly subsidy of $36 a person.

“For them, $36 a month is the sort of thing that can make a difference between keeping coverage and losing coverage,” said Peter Lee, former executive director of Covered California. “We can’t fix everything with that gap, but we can focus the dollars on those who need it most.”

The Walter family, though, may still face a nearly $200 monthly premium payment to cover both of them, $130 more than they previously paid for healthcare and prescriptions through Covered California.

“I can’t afford that, not really,” said Veronica, a pet sitter who works part-time at a school. “A giant state like this with this many people, and this many resources? You can’t just leave the people with nothing for healthcare or healthcare they can’t afford.”

California policy researchers and health advocates acknowledge the limits of a partial subsidy but say that concentrating funds on those who earn less is the most efficient way to maximize impact. People who drop coverage are , healthier, and less likely to have high healthcare costs — all factors that help stabilize the insurance risk pool. Without coverage, Lee said, they’re also more likely to experience debt from medical emergencies or leave unpaid hospital bills that strain the .

Cary Sanders, senior policy director at the California Pan-Ethnic Health Network, a health advocacy group, said the state’s move last year kept low-income enrollment in Covered California steady and reduced racial disparities in coverage.

“It’s working; it’s just that it’s not enough,” Sanders said. “We need the federal subsidies back.”

Still No Help for Many

When Congress passed enhanced subsidies in 2021, it capped monthly premium payments for even the highest earners at 8.5% of income. Those temporary enhancements allowed about 8 million Americans to choose robust plans with no monthly premium payment last year and helped double Obamacare enrollment to of 24 million.

At the end of last year, 22 million of them lost that help when the GOP-led Congress blocked the extension.

The pressures on Obamacare enrollees don’t stop at premiums. Federal legislation Republicans passed last summer known as the also shortens enrollment windows, tightens income verification requirements for subsidies, and requires enrollees who earn more than they projected to pay back the full amount.

Even if Newsom’s proposal passes, most Covered California customers won’t get state help. Nearly 1 million enrollees — 52% — earn above the $31,300-a-year individual earning cutoff.

Victoria Garzouzi was one of many middle-income retirees hit with one of the most extreme premium increases: The monthly payment for her low-level bronze plan jumped eightfold to $1,600.

To make ends meet, she came out of retirement and dipped into her savings. “I’m working to pay for my insurance,” she said. “I am an army of one.”

Despite a $6,000 deductible, her health insurance premium payment is more than the mortgage on her two-bedroom house. She’s putting off a needed cataract surgery until October, when she turns 65 and qualifies for Medicare.

While GOP leaders have not publicly weighed in on the state subsidies, some Democratic lawmakers have questioned why more help hasn’t been proposed.

Assembly member Dawn Addis, who chairs the chamber’s budget subcommittee on health, suggested Newsom could tap an additional $230 million from a fund for healthcare cost relief — money raised from a state penalty levied on those who can afford to enroll in health insurance but choose not to.

Lawmakers have previously criticized state officials for socking away much of the penalty revenue, which was supposed to go toward healthcare affordability. After California discontinued its premium subsidies thanks to increased federal assistance, the Newsom administration said the state was saving to help consumers once those temporary subsidies expired. Instead, California borrowed from the subsidy fund to cover state budget shortfalls, to the tune of $771 million. Starting this year, the subsidy fund should see an influx of cash as the state pays back the loan.

At a May legislative hearing, Joseph Donaldson, then a Department of Finance analyst, said maintaining the reserve was a prudent and financially sustainable approach.

Dylan Roby, a public health professor at the University of California-Irvine who consults for Covered California, said the focus on lower-income enrollees is deliberate. They qualify for federal subsidies that higher earners don’t, maximizing federal investment and strengthening the broader system.

“You end up with more advanced premium tax credits flowing into the state that you would have been leaving on the table,” he said.

State lawmakers have until June 15 to pass a state budget. Then, Covered California’s board would decide eligibility and benefit amounts, a decision that could come this summer, with new subsidies starting Jan. 1.

Even with the extra help, Walter and her husband worry they won’t be able to afford a potential $200 monthly premium payment. Walter said she’d likely have to rely on free clinics or ration medications.

“I take so many pills, I rattle,” she said. “That, on top of the $200? For us, it really adds up.”

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