Affordable Care Act marketplace enrollment has decreased sharply in Missouri, dropping 25% between February 2025 and February 2026, according to a report from analysts at Washington University that examined recently released federal data.
The ACA marketplace is where people who don't have health insurance through the government or their employer can buy plans. Missouri's drop is greater than the national decline – around 12% – in paid enrollments since last year.
As of February 2026, around 261,000 people in Missouri were enrolled in marketplace plans. The data covers people who have paid for and kept their plans, not just those who signed up for coverage during open enrollment.
It's likely the drop is at least partly due to the expiration of pandemic-era subsidies, said Tim McBride, a professor at Washington University's Bursky School of Public Health who tracks insurance enrollment.
While many who live in lower-income households had been eligible to receive federal help to pay their health insurance premiums, 2021's American Rescue Plan Act created enhanced subsidies for enrollees who earned higher incomes.
The enhanced subsidies expired this year, and the premiums for some in Missouri and in southern Illinois were expected to increase by hundreds of dollars a month.
"It's the increase in out-of-pocket premiums," said McBride, who tracked the changes in his health insurance newsletter. "In some cases it's over 100%. To an economist, that's like Econ 101: When the price goes up, you're probably going to get people not buying the product."
Health and Human Services Department officials say the drop is because the administration is cutting down on fraudulent enrollees who lied about how much money they made.
"This law [extending the subsidies], coupled with actions from the Biden-Harris Administration, created the incentive and opportunity for fraudulent, phantom, and improper enrollments," a report from the office of the Assistant Secretary for Planning and Evaluation reads. "The Trump Administration has utilized numerous tools mobilizing a full-scale effort to ensure federal subsidies are going only to those for whom they are intended."
The report claims anti-fraud actions blocked more than 3 million people from claiming subsidies they were not qualified to receive.
McBride said the drop is worth the public's attention, even though those enrolled in individual insurance plans make up a small percentage of Missouri's total health insurance enrollment.
"Most of these people, or in fact more or less all of them we believe, go into the marketplace plans because they have no better option for insurance," he said.
Fewer people with insurance "creates all sorts of problems for health providers," he said. "They all of a sudden have more uncompensated care. [Patients] can't pay their bills, there's more medical debt, they may delay their care. So, these are the kind of things we're worried about, even if it's a fairly small population."
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