Donald Trump’s changes to Obamacare have not repealed the Affordable Care Act, but they have reshaped what coverage costs and who can get it. Enhanced premium subsidies expired at the end of 2025, average monthly premium payments jumped 58 percent for 2026, new verification rules make it harder to enroll and stay enrolled, and the One Big Beautiful Bill Act signed on July 4, 2025 added work requirements and shorter eligibility cycles to Medicaid. If you buy coverage on HealthCare.gov or rely on Medicaid, the practical effect is higher costs, more paperwork, and a real risk of losing coverage during a redetermination.
What Changed for Your 2026 Marketplace Coverage
The single biggest change hitting enrollees is the expiration of the enhanced premium tax credits at the end of 2025. Those subsidies, first enacted through the American Rescue Plan in 2021 and extended by the Inflation Reduction Act in 2022, had pushed marketplace enrollment to a record 24.3 million. Their expiration cut roughly $31 billion in annual federal marketplace funding.1The Commonwealth Fund. Expiring Premium Tax Credits Lead to 340,000 Jobs Lost in 2026 The One Big Beautiful Bill Act did not extend them.2American Medical Association. Changes to Medicaid, ACA, and Other Key Provisions in One Big Beautiful Bill
The impact showed up right away. Average monthly premium payments for enrollees rose from $113 to $178, a 58 percent jump. Average deductibles rose 37 percent to a record $3,786. Shoppers moved toward cheaper, higher-deductible bronze plans, which reached a record 40 percent of selections, while silver plans dropped to a record low of 43 percent.3KFF. What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles
Plan sign-ups for 2026 fell to roughly 23 million, a 5 percent drop and the sharpest single-year decline since the marketplaces launched.4Healthcare Dive. Affordable Care Act Enrollment 2026 CMS Snapshot The Congressional Budget Office projects that “effectuated” enrollment, meaning people who actually pay and keep coverage, will fall to about 16.9 million for 2026, roughly a 25 percent contraction from 2025. Young adults aged 18 to 34 accounted for 46 percent of the sign-up decline, and people with incomes above 400 percent of poverty accounted for 48 percent.3KFF. What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles
Stricter Enrollment and Verification Rules
A second wave of change is regulatory. In June 2025, CMS finalized the Marketplace Integrity and Affordability rule, which repealed the monthly special enrollment period for people earning below 150 percent of the federal poverty level, required pre-enrollment verification for at least 75 percent of new special enrollment period sign-ups, imposed a $5 monthly premium on automatically re-enrolled consumers who had been paying nothing, excluded DACA recipients from marketplace eligibility, and let insurers deny coverage to people with unpaid past-due premiums.5Centers for Medicare and Medicaid Services. 2025 Marketplace Integrity and Affordability Final Rule CMS projected the rule would save up to $12 billion in 2026 and reduce individual market premiums by 5 percent, while estimating that 750,000 to 2 million consumers could lose coverage.6Healthcare Finance News. CMS Final Rule Cracks Down on Improper ACA Enrollments
Cities including Baltimore, Columbus, and Chicago sued to block the rule. In City of Columbus v. Kennedy, a federal district court in Maryland stayed several provisions before the 2026 open enrollment period, including the $5 auto-reenrollment premium, the past-due premium enforcement measure, the special enrollment period verification requirements, and stricter income verification rules.7Centers for Medicare and Medicaid Services. City of Columbus v. Kennedy Impacts The litigation was still pending in late 2025.8Thomson Reuters Tax. Court Delays Key Provisions of Marketplace Integrity Regulations
The One Big Beautiful Bill Act layered on new pre-enrollment verification requirements for premium tax credit recipients, effectively ending automatic re-enrollment without active confirmation from the consumer. It also restricted premium tax credit eligibility to specific categories of lawfully present immigrants.9ASTHO. One Big Beautiful Bill Law Summary
CMS then finalized the 2027 Notice of Benefit and Payment Parameters on May 15, 2026, folding many of the stayed policies back in. The final rule mandates that exchanges verify at least 75 percent of new special enrollment period enrollments, shortens the failure-to-file-and-reconcile window so people who don’t reconcile their subsidies on their taxes lose eligibility after one year rather than two, and eliminates the requirement to accept self-attested income when IRS data is unavailable.10Centers for Medicare and Medicaid Services. HHS Notice of Benefit and Payment Parameters for 2027 Final Rule The rule also removes requirements for standardized plan offerings on HealthCare.gov, allows plans without provider networks to participate in the marketplace, and lowers the essential community provider threshold from 35 to 20 percent. CMS estimated the proposal could cause up to 2 million additional people to lose coverage and reduce federal spending on premium tax credits by $10.4 billion in 2027.11Georgetown University CHIR. Stakeholder Perspectives on CMS Proposed 2027 Notice of Benefit and Payment Parameters
What this means if you use the marketplace: expect more upfront documentation, less flexibility to enroll mid-year, and a real chance that automatic re-enrollment won’t roll you over into a plan the way it did before.
Medicaid Changes That Could Cost You Coverage
If your coverage is through Medicaid, the OBBBA imposed several changes that will phase in through 2026. The law mandates community engagement work requirements of at least 80 hours per month for able-bodied adults aged 19 to 64, with states required to implement the policy by the end of 2026. It shifts Medicaid eligibility redeterminations from an annual cycle to every six months, restricts how states can use provider taxes to finance their Medicaid programs, and cancels Medicaid eligibility for certain humanitarian entrants starting October 2026.9ASTHO. One Big Beautiful Bill Law Summary
Work requirements have a track record. When Arkansas fully implemented the policy under Trump’s first term, more than 18,000 people lost coverage before courts ruled the approval unlawful.12KFF. An Overview of Medicaid Work Requirements The six-month redetermination cycle doubles the number of times enrollees have to prove eligibility, and coverage losses during redeterminations are often driven by paperwork rather than actual ineligibility.
The CBO estimated the OBBBA’s health provisions would cause 11.8 million people to lose coverage by 2034. Combined with the expiration of enhanced subsidies and other regulatory changes, projected coverage loss rises to 16.9 million.9ASTHO. One Big Beautiful Bill Law Summary The CBO also projected the law would increase the federal deficit by $3.4 trillion over a decade while cutting roughly $1.06 trillion from Medicaid and marketplace spending.13American Hospital Association. CBO Projects OBBBA Increase Uninsured 10 Million, Federal Deficit $3.4 Trillion
Whether Medicaid expansion continues in your state may also be at risk. As of 2026, 41 states plus Washington, D.C., have adopted Medicaid expansion, with 10 states still declining. Twelve expansion states have “trigger” provisions that would automatically end or scale back expansion if federal matching rates are cut.14KFF. Status of State Medicaid Expansion Decisions15Georgetown University Center for Children and Families. How Would Changes to Federal Medicaid Expansion Funding Impact People in Trigger States
The Individual Mandate and Short-Term Plans
Two first-term changes still shape your choices. The 2017 Tax Cuts and Jobs Act zeroed out the individual mandate penalty starting in 2019. The legal requirement to maintain minimum essential coverage stayed on the books, but there is no federal financial penalty for going without.16Health Affairs. The Tax Bill and the Individual Mandate
A 2018 final rule from the first term also extended the maximum duration of short-term, limited-duration health insurance from three months to nearly 12 months, renewable for up to 36 months. These plans are not required to cover essential health benefits or pre-existing conditions.17Centers for Medicare and Medicaid Services. Trump Administration Delivers on Promise of More Affordable Health Insurance Options Research found 98 percent of short-term products excluded maternity care and nearly half excluded outpatient prescription drugs. The Biden administration reimposed tighter rules on these plans; in August 2025 the second Trump administration signaled it would stop enforcing those rules and plans to finalize a rollback by the end of 2026. Short-term plans remain available in 36 states and are banned by state law in five, including California, Massachusetts, and New York.18KFF. Examining Short-Term Limited-Duration Health Plans on the Eve of ACA Marketplace Open Enrollment
The Great Healthcare Plan
On January 15, 2026, Trump unveiled the “Great Healthcare Plan,” a one-page legislative framework he asked Congress to enact without delay.19Healthcare Dive. Trump Great Healthcare Plan Affordability ACA It does not repeal the ACA. Its core provisions include codifying “most-favored-nation” drug pricing to match international prices, redirecting premium tax credit payments away from insurance companies and directly to consumers through health savings accounts, funding ACA cost-sharing reductions to eliminate “silver loading” and reduce common marketplace plan premiums by more than 10 percent, ending pharmacy benefit manager kickbacks, and requiring providers and insurers to publicly post pricing, claim denial rates, and overhead costs in plain language.20The White House. The Great Healthcare Plan
The proposal does not include specific provisions guaranteeing coverage for people with pre-existing conditions. The Committee for a Responsible Federal Budget estimated the cost-reducing provisions could save about $50 billion over a decade, while the proposed restructuring of ACA subsidies could increase deficits by up to $350 billion over ten years depending on how it is designed.21Committee for a Responsible Federal Budget. White House Releases Great Healthcare Plan As of mid-2026, Congress has not acted on the framework.
Fraud Crackdown or Affordability Crisis?
The administration and its critics offer competing accounts of why enrollment is falling. HHS Secretary Robert F. Kennedy Jr. told a House committee in April 2026 that “the only people who lost coverage were people who were never entitled to coverage.” CMS Administrator Mehmet Oz reported the agency had identified 1.6 million people “illegally dual-enrolled” in both Medicaid and the ACA marketplace in 2024.22Politico. Obamacare Affordability, Premiums, Fraud, and Midterms Looming The administration has cited research from the Paragon Health Institute estimating roughly 6.4 million people were improperly enrolled in marketplace plans in 2025, costing taxpayers up to $27 billion.23U.S. House Ways and Means Committee. President Trump’s One Big Beautiful Bill Prioritizes America’s Working Families by Ending Obamacare Fraud
State exchange and insurance officials in California, Vermont, and Colorado dispute this framing, arguing the primary driver of coverage loss is the subsidy expiration making premiums unaffordable for middle-income families. Vermont’s Department of Health Access stated: “Fraud is not a driver of coverage loss.” As of late May 2026, CMS had not produced evidence that the 2026 enrollment drop was attributable to fraud.22Politico. Obamacare Affordability, Premiums, Fraud, and Midterms Looming Insurance industry group AHIP argued that existing caps on health plan profits undermine the theory that insurers are broadly profiting from fraudulent enrollment.24AHIP. Health Insurance 101 and Paragon’s Myth of the Phantom Patient
For a household comparing plans, the distinction is largely academic. The premium you’ll see quoted for 2026 reflects the loss of the enhanced credits, and the enrollment process reflects the new verification rules. If your income puts you near a subsidy cliff or you missed a tax reconciliation, the risk of losing eligibility mid-year is higher than it was in 2024. Reviewing your renewal actively, rather than assuming auto-enrollment will handle it, is the practical response.