Nearly a Million Texans Are No Longer Enrolled in the ACA Health Plans They Chose for 2026

Recent federal data show that the number of Texans enrolled in Affordable Care Act (ACA) health plans plummeted from 4.2 million on January 15th of this year to only 3.3 million on February 1st. The data from February show the number of Texans who actually paid their first monthly premium — called “effectuating” their insurance — as opposed to just signing up for their plan.

There is a drop-off most years, but the giant decline this year likely reflects the failure by Congress last year to extend the ACA Enhanced Premium Tax Credits that it established in 2021 to lower costs for more Americans. The original ACA tax credits are still in place, reducing prices for many Texans. However, people who relied on the Enhanced Tax Credits were likely surprised to see the bill received in January and opted not to pay. 

The 3.3 million Texans who “effectuated” their ACA plan by February this year is a slight dip from 3.4 million the prior year. Despite this step backwards, ACA enrollment has skyrocketed in the state over the last decade. From 2015 to 2021, enrollment hovered between 1.1 and 1.3 million before rising to over 3 million, illustrating Texans’ strong support for the ACA health coverage.   

What does it mean that nearly 900,000 Texans dropped their ACA health coverage from January to February?

Texas hospitals are currently feeling the strain of more uninsured people in the state using hospitals for emergency care instead of clinics for primary and specialist care. The financial strain and physical stress of being uninsured and/or having medical debt make health worse every day for Texans across the state. As these uninsured Texans cannot go to the doctor for minor illnesses and injuries, we will see increases in communicable illness and decreases in economic productivity as Texans cannot return to work or school as quickly as they would be able to had they been able to receive basic medical care. With fewer Texans covered by insurance companies to help them pay for clinic and hospital visits, clinics and hospitals will see revenue reductions and have to make difficult decisions about cutting services or laying off workers.

Congress must pass Enhanced Advanced Premium Tax Credits legislation and return affordable health insurance to millions of US and Texas residents who dropped their Marketplace plans or opted for higher-deductible plans. The US House of Representatives already passed this legislation in January 2026; U.S. Senators can demand a vote on this bill despite the Senate leader’s refusal to bring it to the Senate floor for a debate and vote.

Let’s Take Deep Dive Into the Numbers

When people enroll in a plan through the health insurance Marketplace, their plans do not become active until they “effectuate”—or, activate—their plans by paying their first month’s premium payment. While we saw 4,172,233 Texans choose health insurance plans for 2026 by the end of the 2026 Open Enrollment period on January 15, 2026, by February 1, 2026, 895,035 people who selected health insurance plans for 2026 did not effectuate those plans.

While Texas experienced a smaller decline in effectuated enrollment from February 2025 to February 2026 (3,423,543 to 3,277,198—a 4% decline) than many other states, the state still saw a significant drop. Even if we don’t consider the over 850,000 people who enrolled for 2026 but did not activate their plans, the difference in February 2025 effectuated enrollment and February 2026 effectuated enrollment still amounts to more than 140,000 people without coverage. 

The Office of the Assistant Secretary for Planning and Evaluation suggests that the number of people who activated their health insurance plans is much lower because over the past four years, some bad-acting health insurance agents and brokers have exploited the application system and fraudulently enrolled US residents without their knowledge. While that fraudulent activity has occurred in Texas, health insurance agents and brokers cannot automate enrollment systems, so it is unlikely they have fraudulently enrolled hundreds of thousands of people in Texas. Additionally, the federal government has the means and the data to understand how many people agents and brokers have actually fraudulently enrolled by monitoring enrollments from Enhanced Direct Enrollment (EDE) websites. In 2018, the current administration opened EDE sites, which allowed the fraudulent enrollments to take place, and the current administration can shut those sites down just as easily.

We will continue to see increasing numbers of people dropping their Marketplace health plans throughout 2026 as currently-insured people grapple with increasing costs of living and stagnant pay. And the Texas legislature is considering making things worse in the coming 2027 legislative session by transferring the burden of state tax revenue production from property taxes to increased sales taxes. That shift would require low-wage earners who are less likely to own homes essentially to make up for tax cuts for homeowners around Texas.

Overall, for 2026, since Congress failed to maintain health insurance premiums subsidies at 2021 to 2025 levels, in exchange for lower monthly premiums, Texans chose plans with higher deductibles and higher costs to see doctors and get medications. People who enroll in these high-deductible and/or high copay plans often act as uninsured people (avoiding routine and non-emergency health care) do and experience the same negative health outcomes as uninsured people. So even those Texans who are able to keep paying for their health insurance plans will have higher health care costs and will make fewer appointments for preventive, primary, and specialist care. We will see the health care consequences—more advanced chronic illnesses, increases in emergency room visits, shorter life spans, etc.—of these gaps in care in decades to come.

Background and Consequences

Since the American Rescue Plan Act (2021) made health insurance more affordable to people around the United States, the numbers of Texans enrolling into qualified health insurance plans through the Affordable Care Act’s Health Insurance Marketplace nearly tripled. Alongside the Medicaid Continuous Enrollment period that accompanied the public health emergency declaration due to the COVID-19 pandemic, increased Marketplace enrollment helped lead to the lowest rate of uninsured US residents in history (7.9% of the total population uninsured in 2023).

Since many Texas lawmakers continue to refuse to represent the interests and wills of their constituents by closing the health insurance coverage gap and opening Medicaid eligibility to low-income adults, Texas residents’ rates of uninsurance are higher than in any other state in the US (for both adults and children). And because Texas adults over 18 cannot qualify for Medicaid unless they are pregnant or have disabilities, many of those people with low incomes who would qualify for Medicaid instead get health insurance through the Affordable Care Act’s Health Insurance Marketplace, if they can afford it. Marketplace plans cover more people in Texas than nearly every other state in the US.

As noted above, millions more Texans enrolled in Marketplace health insurance plans from 2021 to 2025 because the American Rescue Plan Act (2021) and the Inflation Reduction Act (2022) both: 

  • Increased the amount of financial help (advanced premium tax credits/APTCs) that make Marketplace health insurance affordable; and 

  • Expanded the thresholds for eligibility for APTCs to more people. 

ACA insurance markets were stabilizing, and costs for both coverage and health care services were dropping not only for people covered by ACA plans but for everyone else around Texas and the US who have health insurance through other sources, like employers or Medicare.

Congressmembers’ inaction in 2025 led to the expiration of those increased APTCs and initiated a series of consequences that harm the health and livelihoods of US and Texas residents:

  1. Knowing that Marketplace health insurance plans would cost more, many previous enrollees cancelled their plans from 2025 to 2026 to avoid the additional household cost, which in some cases was over $10,000 per year;

  2. Knowing that fewer healthy people will enroll, many insurers continue to increase premium costs since sick or injured people will use their health plans and cost more to insure;

  3. Knowing that more people would be uninsured and that care for uninsured people causes hospitals to increase service costs for insurance companies who offer employer plans, costs for employers’ and employees’ health plans also increased; and

  4. To make up for the higher uninsurance rates and reductions in payments to hospitals and clinics that Marketplace health insurance plans are no longer making for former enrollees who are no longer enrolled, costs will rise across all health insurance types, including Medicare and TriCare.

We’ll be able to estimate the numbers of people who lost access to the plans into which they automatically enrolled when we see effectuated enrollment numbers for March since the third month of nonpayment leads to plan cancellation.

As more people become uninsured by qualified health plans in Texas, some will look to alternative sources of coverage—those are, junk insurance plans—like limited benefits plans, short term plans, healthcare sharing plans, and others. All of those plans lack guarantees that plan issuers will meet federal standards for guaranteed coverage of all medically necessary health care services without limits on preexisting health conditions that enrollees may have had before enrolling in those plans. As with the proliferation of enrollment into qualified health plans with increased cost-sharing for most people who enrolled in the Marketplace, the proliferation of junk insurance plans will cause more Texans to avoid medical care, accrue medical debt when they must seek care, and have worse health overall.

Conclusion

Effectuated enrollment numbers for 2026 show that Texas uninsurance rates are increasing, and our health care systems, workplaces, and neighborhoods will feel the financial and familial harm of more Texans uninsured. Texas was moving in the right direction, using state law to increase affordability, getting more people enrolled in more affordable plans, and increasing access to preventive, primary, and specialist care. Now, we’re seeing those trends reverse course.

While we work with Congress to pass universal healthcare to provide basic health care services for all US residents, lawmakers must in the meantime pass an extension of the EAPTCs immediately to return coverage numbers to the trends we were seeing before the EAPTCs expired. While universal basic healthcare in the US would be expensive, it would be less expensive over time than the amount of money state and federal governments and charitable foundations spend to recoup payments to hospitals and clinics for uninsured people who receive care there. The consistency of a universal payer system would stabilize US healthcare financing and allow medical providers to set more accurate costs for services to insurance companies and other types of payers, which would still exist under the universal basic model.

For now, while Texas’ uninsurance rates increase, Texans should know to get preventive care when they can at their local federally-qualified health center or their local charitable clinic. If they need to go to the hospital and are uninsured, Texans should ask about the hospital’s charity care program for uninsured people to avoid as much medical debt as possible.

To join Cover Texas Now in working towards better coverage for all Texans, subscribe to our listserv, and be on the lookout for advocacy opportunities leading into the midterm elections and into the state’s 90th legislative session in 2027.

Every Texan