When the American Rescue Plan Act expanded health insurance subsidies during the pandemic, it dramatically lowered premiums for millions of Americans. The government extended these temporary subsidies through 2025, but when they expired in January, enrollment in Affordable Care Act (ACA) Marketplace plans dropped sharply—nowhere more so than in Ohio, which saw a 32% decline between February 2025 and February 2026.
Rural counties took the hardest hit. Across all 30 states using the ACA Marketplace in 2026, nonmetropolitan areas lost approximately 12% of their enrollees during the annual open enrollment period. That compares to 11% in small metropolitan counties and 8% nationwide. The loss wasn't random; it followed directly from the end of enhanced subsidies.
When subsidies were in place, people earning above 400% of the Federal Poverty Level—roughly $132,000 for a family of four—could receive Premium Tax Credits that capped their monthly silver plan premiums at 8.5% of their income. When those enhanced credits ended, this group faced full-price premiums. Though they represented only 3% of total ACA enrollees, they accounted for 27% of the nationwide enrollment drop, according to analysis by KFF Health News.
Rural communities were hit disproportionately because many had higher premiums to begin with. Of the 778 counties that saw the largest premium increases even after accounting for remaining tax credits, 532 were nonmetropolitan areas. That represented 27% of all rural counties. Some rural residents have already lost coverage entirely; a KFF survey found that 9% of enrollees had become uninsured since the open enrollment period ended, while 17% of returning consumers said they weren't sure they could afford their premiums for the rest of the year.
People with lower incomes, who still qualify for federal financial assistance, also saw their premiums rise, but they haven't dropped out at the same rates. The difference matters: those earning less have ongoing subsidies to cushion premium increases, while those above the subsidy cliff lost their protection entirely. It's important to note that open enrollment sign-up numbers often appear higher than actual effectuated enrollment, meaning the real number of people able to sustain coverage throughout the year may be even lower than these figures suggest.
A few states have tried to fill the gap. Colorado introduced Colorado Premium Assistance in 2025, a fund designed to reduce premiums for eligible consumers. New Mexico saw ACA enrollment increase by 18% thanks to its health insurance affordability plan. These state-level efforts show that policies supporting affordability can make a real difference in keeping people covered, offering a potential model for other states facing similar rural enrollment challenges.