A patient registers for care at a mobile dental and medical clinic in August 2025. Nationwide, the number of people buying health plans on Obamacare insurance marketplaces is down by about 833,000 compared with a year ago, according to state and federal data. (Photo by Spencer Platt/Getty Images)

Nationwide, the number of people buying health plans on Obamacare insurance marketplaces is down by about 833,000 compared with a year ago, according to federal data released this week.

Many states are reporting fewer new enrollees, more people dropping their coverage, and more people choosing cheaper and less generous health insurance plans with higher deductibles.

Across most states, Thursday was the last day to enroll for plans that start in February. But nine states and Washington, D.C., have deadlines later this month, so the numbers could change.

There are 21 states with state-run health insurance marketplaces, and the rest use the federal website. The vast majority of states have seen declines in enrollment so far, compared with around this time last year.

Preliminary data released Monday by the federal Centers for Medicare & Medicaid Services shows 22.8 million enrollees, down from a record total of 24.3 million last year.

Premiums have surged as a result of the expiration of enhanced federal subsidies first made available by the American Rescue Plan Act in 2021 and later extended through the end of 2025 by the Inflation Reduction Act. The availability of the subsidies spurred a sharp increase in the number of people buying health plans on the marketplaces. In 2020, 11.4 million people were enrolled in marketplaces through Obamacare, formally known as the Affordable Care Act. More than double that amount enrolled last year.

Congress failed to reach an agreement on extending the subsidies before the end of last year and still hasn’t reached one. As a result, premiums were expected to increase this year by 114% on average — from $888 last year to about $1,904, according to estimates made in September by health policy research organization KFF.

The higher costs appear to be driving many people to forgo insurance or opt for cheaper, less generous plans this year, health officials and analysts say. Several states with state-based marketplaces — including Georgia, Illinois, Minnesota, New York, Vermont, Virginia and Washington — are reporting fewer enrollments this year in comparison with enrollments through early January 2025, according to early data. Other states, such as California, are reporting fewer new enrollees.

“It’s important to consider that this is preliminary data, so this represents people who have signed up and selected the plan — but they probably haven’t received their first premium bill,” said Elizabeth Lukanen, executive director of the health policy research organization State Health Access Data Assistance Center at the University of Minnesota. “Once that happens, I think there’s concern — and it seems very possible — that people may decide to drop coverage. So, the decline could get bigger.

“On the other hand, open enrollment hasn’t closed, so you have two things sort of competing. It seems pretty likely that there will be a decline,” she said.

If the downward trend continues, the nation could see the first decline in enrollment since 2020, Lukanen said, adding that a full picture of income levels and demographics of people who have dropped coverage won’t be clear until the summer.

In Pennsylvania, data updated through Tuesday shows more than 15,000 previously enrolled adults between the ages of 55 and 64 have dropped coverage entirely — the most of any age bracket.

Pennsylvania’s state-based exchange, Pennie, has seen about 15% fewer new enrollments compared with last year. The state is also reporting 1,000 residents dropping coverage per day during open enrollment — with the most coverage losses among people with incomes 150% to 200% of the poverty level. These could include families of two adults and two children with an income between $48,225 and $64,300.

The state is seeing an “unprecedented” number of previously enrolled people dropping coverage, said Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority.

California is reporting 31% fewer new enrollees this year compared with last year, and more than a third of new enrollees are choosing bronze plans — the lowest, least generous coverage tier — up from less than a quarter at this time last year.

In Minnesota, data as of Dec. 3 shows more than half of active enrollees are opting to keep their coverage tier. But of those changing plans, more than a third — 37% — are going to cheaper plans. The state notes a full picture won’t be available until March.

Meanwhile, some states are seeing roughly the same number of enrollees or more. Texas, for example, is reporting about 4.1 million people enrolling this year compared with 4 million last year.

Charles Miller, health and economic mobility policy director at Texas 2036, a policy research nonprofit, said it’s unclear why enrollments are up, but pointed to some clues.

“Texas had a uniquely large population of uninsured individuals eligible for free and inexpensive plans that hadn’t enrolled previously … [and] has more affordable bronze and gold plans than many states,” he said.

He attributes that to a bipartisan state law, enacted in 2021, that had the effect of increasing subsidies for those plans, Miller said.

Nevada is seeing fewer enrollees overall. But compared with this time last year, the state is seeing 29% more people who are actively shopping the website to explore plans, said Katie Charleson, communications officer at the Nevada Health Authority Division of Consumer Health Services.

The state introduced a new public option, according to the Nevada Current, and health officials told lawmakers last week that about 1 in 5 active shoppers are opting for that plan.

In addition to the expiration of the subsidies, the cost of coverage has risen because of other factors, according to insurers. They say they’ve had to raise premiums because of rising prescription drug costs, inflation and workforce challenges, such as provider shortages.

But the enhanced premium tax credits were aimed at buffering those year-to-year changes for Americans with lower incomes, said Trolley, adding that the tax credit structure “helps make sure that [enrollees] don’t see those really larger drops that happen from time to time, sort of from those market forces.”

“When there are broader rate increases of … the total cost of the coverage, the tax credits are structured so that people who get a tax credit don’t feel a lot of that increase. They’re sort of sheltered from it on a year to year basis,” Trolley said. “The tax credit is tied to someone’s income and limits what they pay as part of their income, not necessarily tied to the cost of the coverage.”

She added that she’s also heard from some residents who say they are waiting to enroll in a plan to see if Congress takes action.

“People are leaving the ACA marketplace because the trade-offs have just become harder to justify,” Lukanen said. “What worries me is that when the coverage becomes unaffordable, it isn’t that people suddenly stop needing care. They just lose the protection that insurance offers, and those health care costs don’t go away.”

Lukanen added that if more people forgo coverage, health care services may end up costing the nation more overall.

“If people are going to the doctor and they don’t have insurance, these costs are then just shifted. They’re shifted to hospitals, ultimately to the community and the taxpayer.”

Trolley echoed that, saying she’s concerned about the overall burden on providers in rural counties, which are seeing the highest drops in Obamacare coverage in Pennsylvania.

“Any increase in the uninsured rate is going to further strain providers that are in rural areas, especially — further strain their financial situation,” she said. “We are very concerned about that in Pennsylvania.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

Sarah Simmons, a midwife and co-owner of Maple Street Birth Center in rural Okanogan County, Wash., holds a newborn. Freestanding birth centers can address maternal health inequities, but many are facing mounting financial and regulatory pressures. (Photo courtesy of Sarah Simmons)

Dr. Heather Skanes opened Alabama’s first freestanding birth center in 2022 in her hometown of Birmingham. Skanes, an OB-GYN, wanted to improve access to maternal health care in a state that’s long had one of the nation’s highest rates of maternal and infant mortality.

Those rates are especially high among Black women and infants. Skanes’ Oasis Family Birthing Center opened in a majority-Black neighborhood, offering midwifery services as well as medical care.

But about six months after the center’s first delivery — a girl who was Alabama’s first baby born in a freestanding birth center — the state health department ordered Skanes to shut it down. A department representative informed her that by holding deliveries at the birth center, she was operating an “unlicensed hospital,” she said.

Hospital labor and delivery units are shuttering across the nation — including more than two dozen in 2025 alone. Freestanding birth centers like Skanes’ could help fill the gaps, but they too are struggling to stay open.

They face some of the same financial pressures that bedevil hospitals’ labor and delivery units, including payments from insurers that don’t cover the full cost of providing maternity care.

Birth center owners also must contend with arcane state rules and antipathy from politically powerful hospitals that view them as competition, especially in rural areas with few births.

Nationwide, the number of freestanding birth centers doubled between 2012 and 2022, but more recently the pressures have taken a toll: About two dozen centers have closed since 2023, bringing the total number down to about 395, according to the most recent data from the American Association of Birth Centers.

In November, Pennsylvania Lifecycle Wellness and Birth Center announced it would shut down birth center services, citing pressure from regulatory challenges and sharp surges in malpractice premiums. It had served Philadelphia for 47 years. And New Mexico’s longest-operating freestanding birth center stopped delivering babies in December.

“When a new business opens, within the first three to five years you expect a certain number will close,” said Kate Bauer, executive director of the American Association of Birth Centers. “But we’ve had several long-standing birth centers close [in 2025] and that hits particularly hard.”

In California, which has some of the strictest birth center licensing rules in the country, concern over the closure of at least 19 birth centers between 2020 and 2024 prompted the state legislature to pass a law in October to streamline birth center licensure.

An appealing alternative

Freestanding birth centers are not attached to hospitals and aim to provide a more homelike, less traditional medical setting. They employ midwives and focus on low-risk pregnancies and births. Some also have an OB-GYN or family medicine doctor on staff, and they often have partnerships with nearby hospitals and doctors if more specialized care is required.

Some Black and Indigenous midwives and doulas say birth centers can be helpful alternatives to their community members, many of whom have had experiences in more medicalized settings that left them feeling marginalized, dismissed or unsafe.

Midwife Jamarah Amani, executive director of Southern Birth Justice Network, runs a mobile midwifery clinic serving majority-Black and Latino neighborhoods in Miami-Dade County, Florida. The nonprofit, which aims to make midwife and doula care more accessible, recently bought a building for a freestanding birth center it aims to open in 2027.

“[Midwifery] presents like a luxury concierge-type of service, and our goal is to really change that and to bring it back to the community in a very grassroots way,” Amani said. She added that expanding access to prenatal care could help address inequities in maternal health, as maternal death rates among Black women are three times higher than those among white women.

Freestanding birth centers also can be a solution for communities without a hospital nearby.

The closest hospital to the Colville Indian Reservation, located in northern Washington state, is half an hour away, said Faith Zacherle-Tonasket, founder of the nonprofit xa?xa? Indigenous Birth Justice.

So far, the group has trained nearly a dozen tribal doulas and midwives to serve the area. In the next few years, it plans to open a freestanding birth center. Zacherle-Tonasket said Indigenous-run birth centers are crucial alternatives for tribal women, who also have some of the highest maternal mortality rates in the nation and often face prejudice in clinical settings.

“They don’t feel safe. So a lot of them just don’t get prenatal care,” said Zacherle-Tonasket. “Bringing traditional midwives that are from our own communities, that were born and raised in our communities, that know the families — we know that those babies will be birthed with love.”

Regulatory hurdles

When the Georgia legislature relaxed state health care regulations in 2024, it felt like a long-awaited win for Katie Chubb. A registered nurse and mother of three who’s worked in health and nonprofits, Chubb has spent years trying to open a birth center in Augusta.

The state denied her application to open the center in 2021. Georgia, like many states, requires health care providers to get state approval, called a certificate of need, before they can build a new facility or expand services. Rival providers, like other hospitals, can challenge an application, effectively vetoing their local competition.

That happened in Chubb’s case: Two local hospitals filed letters of opposition against her and refused to say they’d accept emergency transfers from her birth center, another requirement for opening.

Georgia currently has three freestanding birth centers, a fraction of the more than two dozen that operate in neighboring Florida.

“We’re seeing women giving birth in hospital hallways or at home unassisted, because there’s no in-between option like a birth center,” Chubb said. In October, Georgia lost another labor and delivery unit at a rural hospital two hours north of Augusta.

“Women are just left to figure things out.”

In Kentucky, the Republican-controlled legislature passed a bill in March that aimed to clear the way for freestanding birth centers by exempting them from the certificate of need process.

But Republican lawmakers attached a last-minute anti-abortion amendment to the bill, prompting Democratic Gov. Andy Beshear to veto it. The legislature eventually overrode his veto. Midwifery advocates hope the new law will help make it easier to open a birth center in the state.

Georgia legislators similarly revised Georgia’s certificate of need rules in 2024, exempting freestanding birth centers. Chubb, who championed the new law, hoped it would clear the path for herself and others.

But they hit another roadblock. The state still requires birth centers to secure a written agreement with a local hospital to accept transfers of clients in emergencies. Chubb and at least one other prospective birth center owner have been unable to get their local hospitals to sign such transfer agreements.

“We’re still fighting,” Chubb said. “Behind closed doors we’re still working very hard on getting legislation and regulations changed to make opening birth centers more equitable.”

Some hospitals view birth centers as a threat to the viability of their labor and delivery units, siphoning off patients and revenue from a service that’s already unprofitable for most hospitals.

Daniel Grigg, CEO of Wallowa Memorial Hospital, a 25-bed critical access hospital in northeast Oregon, said there aren’t enough births in the area for both hospitals and birth centers.

“When you’ve got a small-volume community like we have, every birth helps the providers keep their skills up and their competency,” he said. “When you’ve got a midwife taking, say, 10 patients out of that pool,” it can have an impact on physicians and hospitals.

Alabama lawsuit

After the Alabama Department of Public Health shut down Skanes’ birth center in 2023, she joined with two other women who had also been attempting to open birth centers in Alabama: Dr. Yashica Robinson, an OB-GYN in North Alabama, and Stephanie Mitchell, a licensed midwife in Alabama’s rural and economically disadvantaged Black Belt region. Together they sued the Alabama Department of Public Health over what they called a de facto ban on birth centers.

The state insisted its tighter regulations would ensure that birth center facilities are safe. The birth center owners said the state’s rules were overly burdensome and clinically unnecessary for the low-risk, nonsurgical births that are attended by midwives. And, they said, the rules prevented more families from accessing care where it’s desperately needed. The state has lost at least three hospital labor and delivery units since 2020.

“Entire swaths of the state are maternity care deserts without access to essential health care,” said Whitney White, a staff attorney with the American Civil Liberties Union, which is representing the birth center owners and their co-plaintiff, the Alabama affiliate of the American College of Nurse-Midwives.

“Hospital labor and delivery units are closing, and pregnant folks are reporting they’re really struggling to access the care they need, struggling to get appointments, struggling to find a provider,” White said.

Last May, an Alabama trial court permanently blocked the state from regulating freestanding birth centers as hospitals. Birth center staff are still overseen by state boards of midwifery and nursing.

All three Alabama centers are now open. But their licensed midwives are delivering babies under a cloud of uncertainty about the future.

The state appealed the ruling in November. The case is ongoing.

Struggles and solutions

Bauer, of the American Association of Birth Centers, said many centers face the same financial barriers. Uncomplicated births at freestanding birth centers cost less than they do at hospitals, but research has shown that insurers, including Medicaid, reimburse centers at lower rates. Some state Medicaid programs don’t cover some of the nonclinical services, such as lactation consultants and doulas, that birth centers may provide. And malpractice premiums are rising.

“We’re volunteering our time, essentially, to keep the birth center open as a service to the community,” said Sarah Simmons, co-owner of Maple Street Birth Center in rural Okanogan County, Washington. The center can’t afford to hire a front-desk staffer or another midwife, Simmons said. She added that on average, the center makes less than a third of what the local hospital makes for providing the same obstetric service.

But there may be solutions to some of these financial problems. For example, the Center for Healthcare Quality and Payment Reform, a national health care policy center, has recommended that health insurance plans, both Medicaid and commercial, pay hospitals and birth centers monthly or quarterly “standby capacity payments” per woman of childbearing age covered by that health plan in the facility’s service area. It also recommends that plans pay a separate delivery fee for each birth.

In 2024, Democratic U.S. senators proposed a bill to allow for a similar payment model.

Standby payments could help freestanding birth centers, especially those that fill gaps in maternity care deserts — but not unless centers receive payments that are comparable to those that hospitals get, said Simmons, whose center serves four sparsely populated counties along with the Colville tribal communities.

“This would be most beneficial to freestanding birth centers if pay parity laws were enforced, so rural freestanding birth centers were paid the same rates for the same services as rural hospitals, ” she said.

State grants also can help, but birth centers say a one-time infusion won’t be enough. In 2024, Washington opened grant applications for distressed hospital labor and delivery units and freestanding birth centers.

Ashley Jones, of True North Birth Center and president of the Washington chapter of the American Association of Birth Centers, said the grant has helped keep their doors open.

Meanwhile, Chubb, the Georgia nurse, recently had to take another job to support her family while her birth center remains in legal limbo.

“I’m just waiting until the government figures out what they’re doing.”

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org. Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.