The official story coming out of Washington is that ACA marketplace enrollment fell in 2026 because the government cracked down on fraud. Tens of thousands of people were enrolled without their knowledge, the argument goes, and now that the rolls have been cleaned up, the numbers look smaller.
That framing is politically convenient. It is also wrong.
The real story is simpler and more damaging: Congress allowed the enhanced premium tax credits to expire at the end of 2025, premiums roughly doubled for millions of enrollees, and people stopped buying coverage they could no longer afford. The market did exactly what markets do when prices spike without warning. People left.
What we are watching is not a fraud cleanup. It is a coverage collapse in real time. And the institutions that will absorb the fallout - FQHCs, safety-net hospitals, community health centers - are already operating in the red.
