The window to shop for 2027 Affordable Care Act coverage opened Sunday in most states. It arrives two days before the midterm elections and after a year in which millions of people walked away from their plans because they could no longer afford them.

About 19.2 million people held marketplace coverage in February. That was 2.6 million fewer than a year earlier, after the larger premium subsidies that Congress approved during the pandemic ran out at the end of 2025. Many enrollees saw their monthly bills more than double overnight.

The losses kept piling up as the year went on. Eighteen states that run their own exchanges said more people dropped out and fewer signed up midyear than usual. Cancellations were up close to a third through May. Estimates show the broader individual insurance market shrank by more than 4.6 million people by June compared with the prior year.

Hard choices for patients

Patients with chronic illness describe painful tradeoffs. A Florida caregiver with lupus said her premium climbed to nearly $1,100 a month before she gave up her plan in April. She later spent a month in the hospital with sepsis. Another Florida woman sold keepsakes and spent the money from her home sale to keep paying, but she loses her coverage on Sunday.

Mississippi offers one of the starkest examples. Its marketplace ended 2025 with about 338,000 people. That fell below 192,000 by February and to roughly 125,000 in September before ticking back up to around 135,000 late last month. Even New Mexico, which uses its own money to help buyers, watched its early gains fade by fall.

Prices rise again in 2027

Benchmark silver plans will cost about 13% more on average next year, according to an analysis of federal and state data. That is far below this year's 58% average jump. The original subsidies in the 2010 law still cover most buyers. In parts of Idaho, silver plans will cost the same or less after that help is applied.

Federal health officials say much of the decline reflects a crackdown on fake or unauthorized sign-ups. A White House task force said in September it was removing 760,000 enrollees. Democrats have made the lapsed help a central issue in races across the country. Republican-held districts make up 55% of enrollees but saw 67% of the drop, according to one nonpartisan health policy group.

Open enrollment runs through Jan. 15 in most states and people who sign up by Dec. 15 get coverage that starts Jan. 1.