About four million Americans have dropped their Affordable Care Act (ACA) insurance coverage this year, as costs shot up after enhanced subsidies expired. The Centers for Medicare and Medicaid Services (CMS) released the figures late Friday, offering the most complete look yet at what happens when Congress lets financial assistance vanish into thin air. The data captures the marketplace after a three-month nonpayment grace period expired, meaning people had plenty of time to reconsider their life choices.

As of February, an estimated 19.2 million people are enrolled in ACA plans - a drop of more than 16 percent from the 23 million who signed up at the end of open enrollment. The Department of Health and Human Services suggested the drop might be due to a crackdown on fraudulent or “phantom” enrollment, which sounds very official. But health analysts point to a simpler explanation: costs. The loss of enhanced subsidies spiked many people’s premiums by double digits, leading to what experts call “sticker shock” - the same feeling you get when you realize your health insurance now costs as much as a small car payment.

“This coverage loss happened at the same time millions of people faced double or even triple digit increases in their premium payments,” said Cynthia Cox, a vice president and director of the ACA program at KFF, in a statement that probably caused a few thousand more people to double-check their bank accounts. Insurers and health policy experts had been warning that a steep enrollment drop was imminent once people’s first premium bills came due, and - surprise - they were right.

This marks the first time ACA marketplace enrollment has dropped since the first Trump administration, following several consecutive years of rapid growth and record high enrollment. So, to recap: Congress let subsidies expire, premiums soared, and millions of people decided they’d rather gamble with their health than pay the price. The rest of the newsletter includes updates on a lawsuit over Medicaid work requirements, PBM lobbying, and Senator Cassidy explaining his vote for RFK Jr. - because nothing says “healthcare policy” like a confirmation hearing for a guy who thinks vaccines cause everything but the common cold.