2026年2月10日 / 美国东部时间凌晨5:00 / KFF健康新闻
在保费补贴大幅削减后，今年选择《平价医疗法案》（ACA）医保计划的美国人比预期更多，但随着医疗成本上升，他们是否会继续保有医保仍有待观察。
这一切都源于2026年开放注册期风波不断的戏剧性事件。国会就拜登政府提供的更慷慨补贴是否延长展开辩论，导致史上最长政府停摆，并让公众将目光聚焦于不断上涨的医疗成本和可负担性问题。
原补贴增强政策——通过降低家庭收入中用于医疗的比例并取消收入上限来扩大资格范围——已于去年年底到期。结果，几乎所有购买ACA医保的人成本都增加了。对一些人来说，尽管仍有较不慷慨的补贴，但其保费支出翻倍甚至更多。
许多专家预计，2025年创纪录的2400万ACA注册人数今年会下降。
罗伯特·伍德·约翰逊基金会高级政策官员凯瑟琳·亨普斯特德表示：“如果你大幅提高某物的价格，经济学告诉我们，很多人会少买或根本不买。”
以下是现在需要关注的问题：
初步数据并非最终结果
国会预算办公室（CBO）在2024年12月告诉议员，不延长增强型补贴将导致2026年220万人失去医保，后续年份人数将进一步增加。韦克利咨询集团分析师也估计，今年将有数百万美国人选择退出医保。
联邦官员1月28日发布的数据显示，联邦医保市场（healthcare.gov）和各州运营的市场中，注册人数同比减少约120万。总体而言，共有2300万注册者，其中包括340万新加入ACA医保的人。
去年同期，注册人数为2420万，其中390万是新注册者。
但情况不止这些初步数据那么简单。
一方面，两年的数据均以联邦市场1月15日（当天结束开放注册期）为统计节点。然而，自行运营市场的州的数据大多仅统计到1月10日或11日，尽管有些州的开放注册期延长至月底。因此，这些数字未能反映最后几天可能发生的情况：各州注册是否激增？或者市场是否出现更多取消覆盖的情况？
此外，这些初步数据混合了新注册的ACA用户和现有客户，其中许多人是自动续期至2026年——这引发了其他问题。
对于现有续期投保人，实际数据数周或数月后才能知晓，即确定有多少人实际支付保费。一些消费者可能未关注续期成本，或寄望国会延长补贴。
这是一个需要牢记的重要因素，因为CBO和韦克利对数百万人失去医保的估计是基于全年覆盖的预测，而非初始注册数据。
爱达荷州医保交易所（Your Health Idaho）执行董事帕特·凯利在1月22日记者会上表示：“未来几周，消费者可能发现实在负担不起保费而取消计划，保险公司也可能因未付款而取消覆盖。”
各州注册模式差异显著
另外19个自行运营交易所的州（及哥伦比亚特区）也出现变化，其中一些州公布了比联邦市场更详细的注册数据。
联邦数据显示，大多数州2026年注册人数低于上一年，北卡罗来纳州降幅最大，达近22%。
少数州——包括新墨西哥州、德克萨斯州、加利福尼亚州、马里兰州及哥伦比亚特区——ACA计划选择人数有所增加。
新墨西哥州增幅最大，初始注册人数同比增加近14%。其他州和华盛顿特区的增幅均为个位数。
新墨西哥州尤为独特，它用本州税收全额抵消所有消费者失去更慷慨联邦税收补贴的影响。其他几个州，包括加利福尼亚州、科罗拉多州、马里兰州和华盛顿州，也用州资金帮助部分注册者。
由国家卫生政策学院支持的22个州市场组成的“州市场网络”表示，初步注册数据令人担忧。与去年同期相比，科罗拉多州计划取消率上升83%，爱达荷州取消率是去年的四倍，弗吉尼亚州取消率翻倍。
加州数据显示，新注册人数同比下降32%。宾夕法尼亚州数据显示，55-64岁（保费最高的群体）和26-34岁年轻人终止覆盖的人数比其他年龄组更多。
宾夕法尼亚州医保交易所管理局执行董事德文·特罗利表示：“我们看到大幅更高比例的人放弃医保。过去两个月，从早期退休人员到小企业主再到农民，约有7万人因无法维持生计而退出。”
2月9日，宾夕法尼亚州公布最终数据，显示注册人数同比下降约2%，但这一数字掩盖了部分影响。该州称，近18%的注册者完全退出医保，老年人和农村居民最有可能离开。
一些共和党人将此归咎于特朗普政府支持的反欺诈措施（包括一系列监管和立法变化），认为此举收紧了系统。尽管其中一些措施被联邦法院暂停未生效，但这些ACA批评者（部分人做出数百万非法注册的争议估计）称，这是注册人数下降的原因。他们此前曾指责更慷慨的补贴导致非法注册或经纪人因佣金怂恿计划转换。
然而，自行运营ACA市场的州报告称此类非法转换很少或没有。与联邦市场相比，州级ACA平台采取了额外保障措施，防止经纪人未经授权获取消费者医保信息。
哥伦比亚特区医保交易所管理局执行董事米拉·科夫曼表示，未返回市场的消费者主要原因是成本。
科夫曼称：“分析未返回市场的人群，一半是小企业主。他们不是欺诈者。”
保费更低，免赔额更高
许多州的现有客户没有选择自动续期，而是大幅转向价格更低的“铜级”计划——这类计划免赔额比银级、金级和铂级计划更高。
州市场网络报告，加州73%的续保成员转向铜级计划，高于去年同期的27%。缅因州铜级计划注册人数现已占所有购买计划的近60%。
乔治城大学健康保险改革中心高级研究员斯泰西·波格表示：“人们在看月度预算能承受什么，寻找更低保费的计划。有些人可能希望不用达到免赔额。”
平均而言，铜级计划年免赔额为7500美元。所有ACA计划均需无自付额或免赔额覆盖某些预防性服务（如疫苗接种、癌症筛查和其他检查），但其他服务需先满足年度免赔额。
亨普斯特德表示，高免赔额可能导致一些患者避免就医。
“人们害怕使用医疗服务，可能拖延治疗直到病情加重。”
她补充说，医院和医生等医疗提供者正准备应对更多负担不起免赔额的投保患者。
“所有人都预计医院将提供更多慈善医疗，这将损害其利润，可能导致裁员、关闭或减少服务。”
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Obamacare sign-ups drop, but the extent won’t be clear for months
February 10, 2026 / 5:00 AM EST / KFF Health News
More Americans than expected enrolled in Affordable Care Act health insurance plans for this year, after premium subsidies were dramatically cut — but it remains to be seen whether they’ll keep the coverage as their costs mount.
It’s all part of a drama that roiled the ACA’s 2026 open enrollment period. Congressional debate over whether to extend more generous subsidies made available under the Biden administration led to the longest-ever government shutdown and focused public attention on rising health care costs and the affordability issue.
The enhanced subsidies, which expanded eligibility both by lowering the percentage of household income people had to pay toward their care and removing an income cap, expired at the end of last year. As a result, just about everyone buying ACA coverage saw their costs increase. For some, what they paid toward premiums doubled or more, even though less generous subsidies remain in place.
Many experts expected ACA enrollment, which hit a record 24 million in 2025, to fall this time around.
“If you raise the price of something a whole lot, economics tell us that a lot of people will buy less of it or not buy at all,” said Katherine Hempstead, a senior policy officer with the Robert Wood Johnson Foundation.
Here are things to watch now:
Initial numbers aren’t final
The Congressional Budget Office told lawmakers in December 2024 that not extending the enhanced subsidies would cause 2.2 million people to lose insurance in 2026, with further increases in following years. Analysts with the Wakely Consulting Group also estimated that millions would opt out of insurance for this year.
Data released Jan. 28 by federal officials showed a year-over-year drop of about 1.2 million enrollments across the federal healthcare.gov marketplace and those run by states. Overall, there were 23 million enrollees, including 3.4 million new to ACA coverage.
At about the same time last year, there were 24.2 million sign-ups, with 3.9 million new to the marketplaces.
But there’s more to it than those initial numbers.
For one thing, both years’ data was pegged to Jan. 15 for the federal marketplace, which closed its open enrollment period that day. But, the data for the states that run their own marketplaces included sign-ups in most cases only through Jan. 10 or 11, even though some held open enrollment until the end of the month. Thus, the numbers don’t reflect what might have happened in those last days. Was there a surge in state sign-ups? Or, conversely, did the marketplaces see more enrollees cancel their coverage?
Additionally, those initial numbers are a mix of newly minted ACA enrollees and existing customers, many of whom were auto-reenrolled for 2026 — which raises other issues.
For existing, reenrolled policyholders, the real figures won’t be known for weeks or months, when it becomes clear how many actually pay their premiums. Some consumers may not have focused on their reenrollment costs or may have hoped Congress would extend the subsidies.
That’s an important factor to keep in mind because the CBO and Wakely estimates of millions losing insurance were based on projections for full-year coverage, not initial sign-ups.
In the coming weeks, “consumers may find they really can’t afford the premiums and cancel their plans, while carriers may also cancel coverage for nonpayment,” said Pat Kelly, executive director of Your Health Idaho, a state-based ACA marketplace, during a Jan. 22 call with reporters.
Sharp differences in state enrollment patterns
Changes are also afoot in the 19 other states (and the District of Columbia) that run their own exchanges, some of which have issued more detailed data about enrollment than the federal marketplace.
Most states saw lower enrollment for 2026 than the prior year, with the biggest drop in North Carolina, where sign-ups fell by nearly 22%, federal data shows.
In a few states — including New Mexico, Texas, California, and Maryland, as well as the District of Columbia — the number of people selecting ACA plans increased.
The jump was largest in New Mexico, with its initial number of people selecting plans up by nearly 14%. Increases were in the single digits in the other states and Washington, D.C.
New Mexico — uniquely — used its own tax dollars to fully offset the loss of the more generous federal tax subsidies for all consumers. A few other states, including California, Colorado, Maryland, and Washington, used state money to help some enrollees.
The State Marketplace Network, a collective of 22 state marketplaces supported by the National Academy for State Health Policy, said initial enrollment figures raise concern. Compared with the same time last year, outright plan cancellations are up 83% in Colorado, disenrollments are four times what they were in Idaho, and Virginia has seen cancellations double.
New enrollments are down 32% in California from the same period last year, according to data from the state. In Pennsylvania, people ages 55 to 64, the group with the highest premiums, and young people 26 to 34 are terminating their coverage in higher numbers than other age groups, state data shows.
“We have drastically higher rates of people dropping their coverage,” said Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority. “We had 70,000 drop in the last two months, from early retirees to small-business owners to farmers not knowing how to make ends meet.”
On Feb. 9, Pennsylvania released final numbers, showing enrollment dropped by about 2% from last year, although that figure masks some of the effects. The state says nearly 18% of enrollees dropped coverage altogether, with older and rural residents being the most likely to fall out.
Some Republicans credited Trump-administration-backed anti-fraud measures, which included a range of regulatory and legislative changes, for tightening the system. Although some of those actions were paused by a federal court and have not taken effect, those ACA critics, some of whom have produced controversial estimates that millions may have been improperly enrolled, say that’s behind the decline. They have previously blamed the more generous subsidies for unauthorized enrollments or ACA plan-switching by commission-seeking brokers.
States that run their own ACA marketplaces, however, reported little or no such unauthorized switching. Relative to the federal marketplace, the state-based ACA platforms employ additional safeguards to prevent brokers from accessing consumers’ coverage without authorization.
Among consumers not returning to the marketplace, the main reason is cost, said Mila Kofman, executive director of the DC Health Benefit Exchange Authority, which runs the district’s ACA marketplace.
“When we looked at who these folks are, half are small-business owners,” Kofman said. “They are not folks committing fraud.”
Lower premiums, higher deductibles
Rather than sticking with automatic reenrollment, existing customers in many states shifted sharply into lower-priced “bronze” plans that come with higher deductibles than silver, gold, and platinum plans.
California saw 73% of renewing members who switched plans move to a bronze plan, up from 27% at the same time last year, the State Marketplace Network reported. In Maine, bronze enrollment now represents almost 60% of all plans purchased.
People are “looking at what works in their monthly budget, looking for that lower premium,” said Stacey Pogue, a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. “Some might be crossing their fingers that they won’t need to meet their deductible.”
On average, bronze plans have an annual deductible of $7,500. All ACA plans are required to cover certain preventive services — such as some vaccinations, cancer screenings, and other tests — without a copayment or deductible, but most everything else is covered only after an annual deductible is met.
High deductibles can lead some patients to avoid seeking medical care, Hempstead said.
“People are terrified to use their care,” she said. “They may delay something until it’s more serious.”
She added that medical providers, including hospitals and doctors, are bracing for an increase in the number of insured patients who can’t afford to pay their deductibles.
“Everyone is anticipating that hospitals will have to give out more charity care, which will hurt their bottom lines and might lead them to have to lay off people or close or reduce services,” she said.
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