A total of 14.3 million people enrolled in ACA programs in 2024 were ineligible.
That single finding sits at the center of a new Paragon Health Institute analysis, and the price tag attached to it is staggering. Improper enrollment across both the Affordable Care Act exchanges and Medicaid expansion cost the federal government $65 billion in 2024 alone.
The report pulls together two streams of data, improper Medicaid expansion enrollment and Paragon’s earlier estimates of improper exchange sign-ups, to arrive at the 14.3 million figure. The conclusion is stark. According to the original report, Paragon described the $65 billion total as “not a trivial administrative error” but rather “the predictable result of programs that reward enrollment while weakening incentives to verify eligibility.”
The numbers are also moving in the wrong direction. Improper exchange enrollment jumped more than 26% between 2024 and 2025, reaching 6.5 million total enrollees. Paragon’s report warns that without a change in policy incentives, the problem will keep growing in both the exchanges and Medicaid expansion.
A separate Paragon study, published in June 2026, adds more weight to the concern. It found that nearly 27% of all ACA exchange enrollments this year were improper. Taxpayers are projected to pay roughly $25 billion in improper subsidies in 2026 alone, an amount that represents close to one quarter of total projected ACA subsidy spending for the year.
The financial exposure does not stop there. A KFF analysis published in July found that premiums on ACA exchange plans are likely to rise by double digits in 2027, adding another layer of cost pressure to a program already under scrutiny for its enrollment controls.
Paragon’s core argument is structural. The report contends that the current system is built in a way that prioritizes adding enrollees over confirming that those enrollees actually qualify. Until that changes, the report says, improper enrollment will remain a persistent and expensive feature of both programs rather than an occasional mistake.
The $65 billion figure covers just one calendar year. With improper exchange enrollment already up sharply heading into 2025, and projected subsidy waste climbing toward $25 billion for 2026, the cumulative cost of lax eligibility standards across the ACA system is now measured in the hundreds of billions of dollars over time.