How did changes in income eligibility from 2024 to 2026 impact enrollment among adults, children, pregnant people, and elderly populations?
Executive summary
Changes to income-based eligibility and subsidy rules between 2024 and 2026 shifted who can get Marketplace help and raised costs for many enrollees: around 1.6 million Marketplace enrollees with incomes above 400% FPL face losing subsidies in 2026 if enhanced credits expire [1], and nearly all Marketplace enrollees relied on subsidies in 2024 — CMS reported 91% of 21 million enrollees received a subsidy in 2024 according to one analysis [2]. Regulatory and statutory changes in 2025–2026 also tightened documentation, repayment and filing requirements that affect low‑income and immigrant applicants and may reduce enrollment unless states act [3] [4] [5].
1. Who gained or lost eligibility: the headline shift for middle‑income adults
The major 2026 change is the return of the so‑called “subsidy cliff” for people with incomes above 400% of the federal poverty level: the temporary enhancements that made middle‑income adults eligible for premium tax credits through 2025 end unless extended, meaning roughly 1.6 million enrollees above 400% FPL would no longer get subsidies and would face much higher premiums in 2026 [1]. HealthInsurance.org and KFF explain that these enhanced premium tax credits originally expanded affordability above 4× FPL and that people above that threshold will “no longer be eligible for financial help” if the enhancements expire [6] [1].
2. Children and families: eligibility tied to indexed poverty lines and state choices
Eligibility for children and family members remains governed by federal poverty level (FPL) thresholds that are indexed annually; whether a family keeps subsidies depends on projected household income and those FPL values used for the upcoming coverage year [7] [4]. Advocacy groups warn that new rules — including H.R. 1 changes that lift caps on premium tax credit repayments and freeze some low‑income special enrollment options — increase the financial risk for low‑ and moderate‑income families and could discourage enrollment or cause later tax liabilities [3] [8]. States that adopt streamlined enrollment or preserve special enrollment pathways can blunt those effects, but H.R. 1 and federal rule changes make outcomes uneven across states [9].
3. Pregnant people: not singled out in available reporting
Available sources do not specifically single out pregnant people for different treatment in the 2024–2026 income‑eligibility changes; the reporting frames changes around household income bands, FPL percentages, and program rules that apply to all eligible Marketplace enrollees [7] [1] [4]. However, because pregnant people are often in family units with shifting incomes and are sensitive to SEP and documentation rules, the broader tightening of special enrollment and repayment rules — including limits on the low‑income SEP and higher potential repayment obligations — could raise barriers for pregnant people who rely on Marketplace subsidies [3] [8].
4. Older adults and retirees: the interaction with Medicare and subsidy planning
Retirees and near‑65 adults face two pressures: some lose Marketplace subsidies when they transition to Medicare, and those who remain in the Marketplace risk losing the expanded subsidies in 2026 — prompting tax‑aware income strategies for retirees to preserve subsidy eligibility. Analysts point out that 91% of 21 million Marketplace enrollees in 2024 received subsidies, so the rollback of enhancements in 2026 especially affects older adults who are not yet Medicare‑eligible and relied on those credits [2]. Advisers recommend income planning to avoid “cliff” effects during retirement transitions [2].
5. Administrative and documentation changes that affect enrollment rates
Beyond income thresholds, regulatory changes finalized in 2025 increased verification and filing requirements tied to premium tax credits: CMS finalized a policy to notify and remove advance premium tax credit (APTC) eligibility after two consecutive years of failing to file and reconcile taxes, and other rule changes reduce auto‑renewal protections — both measures can depress enrollment among people who miss filings or rely on passive renewals [5] [10]. At the same time, H.R. 1 removed low‑income SEP protections and raised potential repayment exposure for low‑income consumers, which Georgetown’s Center for Children and Families says could deter enrollment [3] [8].
6. Geographic and legal patchwork: state variation and litigation
States matter. Several of the regulatory changes (for example, eased enrollment documentation or DACA recipient access) were blocked or limited in courts and some policy pauses mean not all changes were applied uniformly in 2026; states that proactively adopt streamlining rules or preserve safety nets can offset federal tightening, while other states may see enrollment declines [6] [9] [8]. In short, the effect on enrollment depends on the intersection of federal policy, court orders, and state implementation choices [9] [6].
7. What the reporting doesn’t say and where uncertainty remains
Available sources document the major mechanics — expiration of enhanced credits, renewed 400% FPL cliff, tax‑filing and repayment rules, and state variability — but they do not provide a single nationwide enrollment tally showing exactly how many children, pregnant people, or elderly individuals disenrolled because of income‑eligibility changes in 2026; granular demographic enrollment impacts are not found in the current reporting [1] [2] [5]. Policymakers and researchers will need enrollment and claims data by age and circumstance to quantify final impacts.