BIRMINGHAM, Ala. — More than 94,000 fewer Alabamians are enrolled in Affordable Care Act coverage compared with last year, a sharp drop that health advocates tie to the expiration of federal subsidies and rank among the steepest declines in the nation.
The loss of coverage comes as the Trump administration and Republican Congress allowed the enhanced premium tax credits, expanded during the pandemic and extended through 2025, to expire at the end of last year. Without those credits, marketplace premiums in Alabama jumped by double digits, and analysts warned that as many as 130,000 residents could ultimately lose coverage.
“More than 94,000 fewer Alabamians enrolled in health care coverage under the Affordable Care Act in February of this year,” according to reporting by The Associated Press, with advocates warning of increased emergency room use as more people go uninsured. Mary Elizabeth Marr, CEO of Thrive Alabama, tied the drop to the subsidy expiration and the state’s decision not to expand Medicaid, saying the loss of ACA subsidies has driven a 50% to 100% increase in the cost of health insurance this year.
Alabama’s losses are part of a broader national pullback in ACA enrollment, but the state’s refusal to expand Medicaid has left it more vulnerable than many others. Alabama is one of only 10 states that has not adopted Medicaid expansion under the ACA, leaving hundreds of thousands of low-income adults in a “coverage gap” — earning too much for traditional Medicaid but too little to afford unsubsidized marketplace plans. In 2023, about 12.3% of working-age adults in Alabama lacked health insurance, slightly above the national average of 11.3%, and nearly a quarter of adults below 138% of the federal poverty line were uninsured. Roughly 477,000 Alabamians were enrolled in the marketplace in 2025, with about 98% receiving premium tax credits; KFF estimated that without the enhanced credits, average benchmark premiums in Alabama could rise about 93%, pushing many out of the market.
By comparison, states that expanded Medicaid and run their own exchanges saw smaller declines. North Carolina and Ohio each lost more than 20% of their ACA enrollees, while Florida shed nearly 260,000, but Alabama’s combination of non-expansion and heavy reliance on subsidized marketplace plans magnified the affordability shock.
The core problem, according to advocates and insurers’ own filings, is cost. Alabama insurers filed 2026 premium increases of 19.3% for Blue Cross Blue Shield, 20% for UnitedHealthcare and 25% for Celtic Insurance, making plans unaffordable for some once the enhanced credits expired. Federal data show Alabama’s marketplace enrollment fell from 477,838 in 2025 to 455,776 in early 2026, a 4.6% decline, or about 22,000 fewer people, with advocates expecting the full-year loss to be much larger. A Kaiser Family Foundation study estimated about 130,000 Alabamians could lose ACA coverage if the enhanced tax credits were not renewed, as premiums for those enrolled in the marketplace were projected to rise by an average of 93% in the state.
Advocates say the Republican-controlled Congress chose not to extend the enhanced credits in the 2025 budget deal, instead prioritizing other spending, and President Trump has pushed to replace the subsidies with a different approach that has not yet protected Alabamians from the current coverage losses.
41 states saw ACA enrollment declines in 2026, with the steepest percentage losses in Ohio and Oklahoma, each down more than 30%, and major drops in Arizona, South Carolina, Indiana, Michigan, Mississippi, Louisiana and Missouri. Florida, despite losing nearly 197,000 enrollees, remained the largest marketplace state at 4.54 million. Texas and California saw modest gains, highlighting how state policy choices and outreach efforts can blunt the impact of subsidy changes.
Alabama’s situation underscores how the lack of Medicaid expansion, combined with the expiration of enhanced credits, has pushed coverage out of reach for many working families. Health policy groups, including Alabama Arise, are urging state lawmakers to revisit Medicaid expansion and close the coverage gap, while also calling on Congress to restore robust subsidies. But with Republicans controlling both chambers of Congress and the White House, prospects for a quick fix remain uncertain.
For now, tens of thousands of Alabamians are navigating a new reality of higher premiums, narrower networks and, for some, no coverage at all — a situation that advocates say was entirely preventable.