33,000 Fresno-Area Residents Lost ACA Coverage After Congress Let Premium Help Expire — More Drops Expected — Photo: Harrison Keely — CC BY 4.0, via Wikimedia Commons
33,000 Fresno-Area Residents Lost ACA Coverage After Congress Let Premium Help Expire — More Drops Expected
Affordable Care Act enrollment dropped across five Central Valley congressional districts in 2026, with Fresno-area losses ranging from 2% to 7% after Congress let enhanced federal premium tax credits expire at the end of 2025, according to an October 8 analysis by health policy research organization KFF.
Congressional District 5, covering portions of Fresno and Madera counties, recorded the steepest percentage decline at 7% — approximately 33,000 residents enrolled in 2026, down 2,000 from 2025. District 13, also covering portions of Fresno and Madera counties, saw approximately 37,000 enrolled, down 2,000, or 4%.
District 20, spanning portions of Fresno, Kings and Tulare counties, recorded approximately 22,000 enrolled, down 1,000, or 6%. District 21, covering portions of Fresno and Tulare counties, saw approximately 29,000 enrolled, down 594, or 2%. District 22, covering portions of Kings and Tulare counties, recorded approximately 24,000 enrolled, down 1,000, or 5%.
Combined enrollment across the five districts totaled approximately 145,000 people in 2026, based on rounded figures published by KFF. Marketplace coverage accounted for between 3% and 5% of the population in each district.
The Central Valley declines occurred alongside a nationwide reduction. According to a June 26 Department of Health and Human Services report, effectuated enrollment declined from 24.2 million people in 2025 to 19.2 million in February 2026 — a 5 million drop, or approximately 13% decrease. It marked the first national enrollment decline in seven years.
Premium costs doubled on average from 2025 to 2026 after Republican lawmakers let the enhanced premium tax credits expire. Democrats shut down the government in October 2025 attempting to negotiate a three-year extension of the credits that would have kept prices low, according to NPR.
KFF reported that a follow-up survey of 2025 Marketplace enrollees found 1 in 10 respondents had become uninsured in early 2026. Among those who maintained coverage, premium payments increased by an average of 58%, while deductibles rose 37%, or approximately $1,000 per person.
“When their costs went up, many of them dropped their coverage,” Cynthia Cox, director of KFF’s Program on the ACA, told NPR.
The Trump administration has attributed the drop in enrollment to attempts to address fraud. “The marketplace doubled in size during the period when there were enhanced subsidies because the coverage was much more affordable and much more appealing to people,” Cox told NPR. “The main takeaway is that enrollment is down 13% from last year. While the Trump administration attributes this drop in enrollment to their attempts to address fraud, this coverage loss happened at the same time millions of people faced double or even triple digit increases in their premium payments with the expiration of enhanced tax credits.”
Stacey Pogue, senior research fellow at the Georgetown Center on Health Insurance Reforms, told NPR: “I don’t see data that point to that conclusion that a 5 million person drop can be explained by allegations of fraud. There’s lots of evidence pointing to people making decisions based on what they can pay each month.”
The idea that enrollment growth was due to massive fraud is a theory advanced by the Paragon Health Institute, a conservative think tank that’s influential in the Trump administration, according to NPR. Many health policy experts are skeptical, according to the report.
Nationally, KFF found that Republican-held congressional districts accounted for 67% of the decline in Marketplace enrollment, despite representing 55% of current enrollment. More than half of ACA enrollees live in Republican congressional districts, according to KFF.
Several insurance companies have announced they will not be participating in ACA markets next year, including Cigna, according to NPR. According to a Georgetown analysis, early insurance rate filings for 2027 show that rates will be going up again next year.
The Breakdown
- Enhanced federal premium tax credits, which made ACA marketplace health insurance more affordable, expired at the end of 2025 after Republican lawmakers in Congress let them lapse.
- Democrats shut down the government in October 2025 attempting to negotiate a three-year extension of the credits.
- Without the credits, average premium costs doubled from 2025 to 2026.
- Five Central Valley congressional districts covering portions of Fresno, Kings, Madera and Tulare counties lost a combined total of approximately 6,594 enrollees, though the exact figure is uncertain because KFF rounds enrollment estimates to the nearest thousand.
- The Trump administration says the enrollment drop reflects its efforts to address fraud; health policy experts say the data shows people dropped coverage because they couldn’t afford the doubled premiums.
What This Means for You
This is a direct consequence of who you elect to Congress and the White House. Republican lawmakers chose to let the enhanced premium tax credits expire, doubling costs for roughly 145,000 Central Valley residents who buy insurance through the ACA marketplace. Democrats fought to extend the credits but didn’t have the votes. The result: thousands of your neighbors lost coverage, and those who kept it are paying double.
The Trump administration is telling you the drop is about fraud prevention. KFF and Georgetown experts are telling you it’s about affordability — people making budget calls when premiums doubled. Those are competing explanations for the same outcome, and which one you believe affects how you judge the officials who made the call.
This matters for your 2026 congressional votes. The enhanced credits are gone because Congress let them expire. Whether they come back, and whether premiums keep climbing, depends on who holds the House and Senate after November.
What to Watch
KFF expects national enrollment to decline further through the remainder of 2026. Watch whether the losses continue in the next KFF district-level analysis.
The Trump administration says fraud explains the drop. What evidence would settle that? A detailed accounting of how many enrollees were removed for fraudulent applications versus how many simply stopped paying premiums they couldn’t afford.
The Georgetown analysis says 2027 premiums are on track to rise again. If they do, and if enrollment keeps falling, insurers may pull out of more markets — Cigna already announced it’s leaving. Cox at KFF says we’re not worried about a death spiral at this point, but the trajectory is worth tracking.
The marketplace doubled in size when the enhanced credits were available. Now that the credits are gone, what happens to people who lost coverage? If they end up in emergency rooms, that cost doesn’t disappear — it shifts. The sources don’t quantify that, but it’s a real cost-benefit calculation worth demanding from the officials who made the call.
Republican-held congressional districts accounted for 67% of the enrollment decline nationally, despite representing only 55% of current enrollment. That’s a disproportionate hit to the constituents of the lawmakers who let the credits expire. Whether that affects how those districts vote in November is the market test of the decision.
