Florida lost roughly 450,000 Affordable Care Act enrollees in 2026 after Congress allowed enhanced federal premium subsidies to lapse — the largest drop in raw numbers of any state — and the Trump administration and healthcare policy analysts remain sharply at odds over why people left the program.

At 40%, Florida has the smallest proportion of its workforce receiving health insurance through an employer of any state in the nation. The state also has one of the highest rates of individuals under age 65 who are uninsured, as well as the highest number and proportion of users of health insurance subsidies under the Affordable Care Act, also known as the ACA or Obamacare.

In December 2025, Congress let ACA subsidy increases that had been put in place during the COVID-19 pandemic lapse. At the time, policy analysts and scholars predicted dire consequences for Florida. The decision not to extend the increased government subsidies of health insurance premiums came after heated partisan debate in Congress and the longest federal government shutdown in U.S. history.

Robert Applebaum, a gerontologist interested in healthcare policy and Senior Research Scholar in Gerontology at Miami University, examined ACA enrollment data from the period since the subsidy changes took effect to assess how Florida residents were affected and how the state compares with the nation overall. In July 2026, the health policy research group KFF reported the most recent available ACA enrollment data on people who both enrolled and paid their first insurance premium — a process known as effectuated enrollment. The data covers the period from January 2026 through the end of February 2026.

Who buys health insurance through the ACA

While the majority of American workers between the ages of 19 and 64 receive health insurance through their employers, many people — especially those who are self-employed or working for smaller businesses — do not. Florida has long had, and continues to have, the most individuals insured through the ACA of any state, with more than 20% of Floridians under age 65 using the ACA, compared with 7% for the nation overall. Florida is also among the states that have declined to expand Medicaid eligibility under the ACA, which limits Medicaid as an alternative for many low-income adults in the state.

The subsidy change controversy

Under the original ACA legislation that President Barack Obama signed into law in 2010, everyone whose premium was subsidized by the federal government was required to contribute to their insurance plan premium. People earning 115% of the poverty level — $18,000 in 2010 — contributed 2.1% of the plan's cost, while those earning 400% of the poverty level, which was $60,240 in 2010, contributed 10%. Individuals earning above that amount were not eligible for the subsidy.

In 2021, in hopes of alleviating economic pressures during the pandemic, Congress passed the American Rescue Plan Act, legislation eliminating premiums for people with the lowest incomes and reducing the cost for people with higher incomes by capping their contributions at 8.5% of income; those enhancements were later extended through 2025 by the Inflation Reduction Act of 2022. The 10% of ACA enrollees making more than 400% of the poverty level, or $128,000 in 2021, became eligible for a subsidy for the first time. In the period following these changes, the number of effectuated enrollees increased from 13.5 million in 2022 to 21.8 million in 2025 — in other words, the increased subsidies made the ACA far more attractive to healthcare consumers, as intended.

A June 2026 report from the U.S. Department of Health and Human Services stated that almost 3 million people who received a subsidy in 2025 lost coverage in 2026. The report suggested the subsidies were not appropriate because many recipients were high-income individuals, and it claimed others were eligible for other public insurance programs, such as Medicaid. Trump administration officials have additionally contended that these improper enrollments were the result of widespread fraud. Many healthcare policy analysts disagree with the fraud claims, noting that partisan politics have now become part of the dissemination of government reports.

Enrollment outcomes so far

The rollback in subsidy amounts increased premiums for people buying insurance through the ACA by an average of 37%, or $1,000, per year nationally. As expected, the increase in out-of-pocket costs meant fewer people bought insurance through the ACA: in 2026, 19.1 million Americans had an effectuated health insurance enrollment through the ACA, a 12.4% drop from 2025.

That decline was not distributed evenly across all 50 states. Ohio and Oklahoma tied for the largest drop, each with a 32% decrease in ACA enrollments. Of the seven states with the highest ACA proportional enrollments, three had among the highest rates of people dropping ACA coverage in the nation, with South Carolina losing 29%, Mississippi 26%, and Alabama 23%. Utah saw a decrease of 16%.

Florida's effectuated enrollment in the ACA fell 10%, from 4.3 million to 3.85 million. Though the proportional decline was smaller than in other states, this was the largest number of people in any state who dropped coverage. Texas recorded a 4% decline and Georgia 8%. ACA enrollment rose in only one state, New Mexico, where it increased 14%, and was unchanged in Illinois. States that had enacted policy changes to financially support ACA premiums, such as funding their own subsidies, saw smaller declines in enrollment.

For Florida, it is not yet clear what the decline of 450,000 enrollees in ACA plans will mean for the overall state uninsured rate. Some may transfer to a spouse's policy, while others may find a lower-cost catastrophic insurance policy. The complete picture will not emerge until 2027, when the state uninsured rates are released.

The 2025-26 enrollment changes showed that 2.7 million Americans left the ACA exchange, and 1 in 10 of them reported becoming uninsured. Prior to the subsidy rollbacks, healthcare policy analysts had predicted that about 6 million people would leave the ACA exchange, with an estimated 80% of them — 4.8 million people — becoming uninsured. So far, the outcome has not been as bad as they feared.

Still enrolled, but with less coverage

One possible reason is that consumers opted for less coverage rather than dropping it altogether. ACA marketplace plans are sold in metal tiers — bronze, silver, gold and, less commonly, platinum — that indicate the share of health care costs a plan is designed to cover; bronze plans carry the lowest premiums but the highest deductibles and out-of-pocket costs, while gold plans pay a larger share. The 2026 data shows a large drop in the proportion of individuals purchasing the middle-level silver plans — from 56.2% to 42.6% — and, at the same time, a substantial increase in people enrolling in the lower-cost, lower-coverage bronze plans, from 29.9% to 39.6%. There was also a curious result: a modest increase, from 13.2% to 17.2%, in enrollment in the higher-level gold plans.

What's next

It bodes well, Applebaum writes, that fewer people than expected dropped their ACA insurance coverage. But as the cost of housing, fuel, and groceries continues to rise, rising insurance premiums may force more people to drop even catastrophic coverage. That creates a ripple effect: when patients cannot afford health insurance, the cost of caring for them puts more financial pressure on hospitals and medical practices. This can lead to reduced services and closures, making healthcare more difficult to access for everyone — not just those on the ACA marketplace.

Robert Applebaum is a Senior Research Scholar in Gerontology at Miami University.

This article is republished from The Conversation under a Creative Commons license. Read the original article. This story was originally featured on Fortune.com.