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This article first appeared on NCLocal.
Enrollment in health plans under the Affordable Care Act declined in nearly every North Carolina county this year, according to preliminary data released by the Centers for Medicare & Medicaid Services in March.
Already, early 2026 data showed North Carolina recorded the sharpest drop nationwide in residents enrolling—a drop-off largely attributed to Congress allowing COVID-era premium subsidies to expire.
Only two counties, both in far Western North Carolina, saw increases in 2026 in the number of people enrolling.
As NC Local previously reported, the expiration of enhanced health care premium subsidies at the federal level likely drove a sharp statewide enrollment decline. As costs increased without additional funding through the subsidies, some North Carolinians had to opt out of health care coverage.
Preliminary data released in January showed that North Carolina recorded 214,000 fewer Affordable Care Act (ACA) enrollments this year compared to 2025, about a 22% decline, the largest drop in the country.
Explore this map to see how many people enrolled in the ACA health coverage this year in each North Carolina county and the year-over-year change from 2025.
Key Takeaways
- All but two North Carolina counties saw enrollment declines, according to an NC Local analysis.
- Cherokee County experienced a 26% enrollment increase, according to the data, while its neighbor to the west, Clay County, saw a 67% increase. It’s unclear what caused the jump.
- Edgecombe County in eastern North Carolina experienced the steepest decline, with a more than 55% drop in 2026 compared to the year before. In 2025, the rural county of 49,000 people tallied more than 5,300 enrollments, or 11% of residents. In 2026, nearly 3,000 fewer people enrolled, according to the data.
Last year, more than 975,000 North Carolina residents, about 9% of the state’s population, enrolled in coverage under the ACA.
Nationally, fewer than 23 million people enrolled in health coverage under the ACA for 2026, according to CMS data. In 2025, more than 24 million enrolled.
Still, these preliminary figures don’t reflect individuals who might have dropped their ACA coverage in 2026, which experts feared would happen as out-of-pocket costs increased.
Earlier this week, NOTUS reported that more than one in five people who signed up through the federal marketplace Healthcare.gov, which is used in North Carolina, were dropped from plans because they didn’t pay the first month’s premium. The report cited internal CMS documents.
Additionally, many people who enrolled this year were forced to pay more for the same coverage or choose more affordable options with higher deductibles, NC Local previously reported.
Preliminary CMS data illustrate that trend, according to an NC Local analysis, with some North Carolina counties seeing an average out-of-pocket cost increase as high as 30% or more compared to last year.
If you’ve lost coverage, KFF Health News recommends discussing private pay or other financial options with your medical provider and looking for cost-saving measures on prescription drug expenses.
Meanwhile, some people are choosing to purchase short-term policies, which have coverage limitations and fewer protections. Community health centers, which treat patients regardless of ability to pay, are another option. Local health departments may also provide access to services for uninsured and underinsured people.
Some professional associations are providing plan options for their members. For example, NC Realtor, a trade association for thousands of realtors, offers Anthem health care plans for purchase by members. The NC Dental Society also offers plan options for members.
This article first appeared on NCLocal and is republished here under a Creative Commons Attribution-NonCommercial 4.0 International License.