Discrepancies in ACA Enrollment Predictions: A 2025 Analysis
In 2025, several organizations predicted enrollment trends for the Affordable Care Act (ACA) without the continuation of expanded subsidies. Many used these forecasts to guide legislative decisions. However, an analysis of actual enrollment data reveals discrepancies between the predictions and reality.
The Congressional Budget Office (CBO) anticipated a decline in ACA plan enrollment from 22.8 million in 2025 to 18.9 million in 2026 if expanded subsidies weren't extended. They projected a reduction of around 4 million enrollees. Yet, actual figures showed a smaller decrease from 24.2 million to 23.1 million during the same period.
More significant than total sign-up numbers, CBO's focus was on effectuated enrollment—individuals maintaining coverage by paying premiums. Their projections accurately estimated a drop from 21.8 million in February 2025 to 19.2 million by February 2026. Factors influencing effectuated enrollment include plan affordability and marketplace integrity checks eliminating improper enrollments.
Before the subsidy expansion ended, forecasts suggested substantial losses for low-income enrollees struggling with higher premiums. Contrary to these predictions, the Urban Institute anticipated a decrease to 11.7 million subsidized enrollees, yet actual numbers were 19.2 million in February 2026. The Department of Health and Human Services (HHS) reported that integrity efforts terminated around 2.9 million improper enrollments, significantly influencing these figures.
State-level predictions also miscalculated enrollment declines, with Texas even experiencing an increase. This suggests potential misalignment with anticipated consumer behaviors, possibly due to a lack of accounting for improper enrollments in forecasts.
Further examination revealed a decrease in enrollment among individuals below 150% of the federal poverty level (FPL) by 441,000. However, there were gains within those earning 100-138% of the FPL. This inconsistency highlights the effect of improper enrollments and significant subsidy shifts, concentrating such activity in certain income brackets.
Returning to initial ACA subsidy levels raised coverage costs across all income groups. The Paragon Health Institute noted that it was easier to improperly enroll individuals into fully subsidized plans when premiums were unpaid, particularly affecting the 100-138% FPL bracket. Meanwhile, enrollees in the 300-400% FPL range attempted to avoid the subsidy cliff to maintain financial support, explaining certain enrollment increases.
Accurate data and analysis are imperative for lawmakers developing future healthcare policies. Addressing issues such as improper enrollments and structural weaknesses in the ACA is vital for informed decision-making in healthcare coverage planning.