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Circulating cell-free DNA (cfDNA) assays are being widely adopted in oncology and maternal-fetal medicine. Patterns of cfDNA fragmentation can provide useful information about gene regulation and expression in human disease from a blood draw. Here, we demonstrate that enhancer RNA expression - a marker of enhancer activity - can be inferred from local patterns of cfDNA fragmentation. We define a transcriptional activation score (TAS) that predicts expression of enhancers and genes based on cfDNA fragment sizes and positions near transcriptional start sites (TSSs). The TAS identifies activity of cancer-associated enhancers in patients with cancer, distinguishes clinically relevant cancer subtypes, and identifies activation of enhancers associated with treatment resistance and therapy response. We propose a simple model to account for our findings based on chromatin fiber structure and the depletion of H1 histone proteins near active TSSs. Our model provides a unified framework that reconciles seemingly conflicting observations from prior fragmentomics studies. Ó³»­´«Ã½ly, this work enables blood-based assessments of gene regulation in cancer and non-oncologic diseases to inform pathobiology, diagnosis, and treatment selection.