Dive Brief:
- Enrollment in Affordable Care Act plans for 2026 is dragging compared to 2025, but remains higher than market watchers anticipated given the sharp premium increases facing consumers this year.
- On Monday, the CMS released its latest snapshot of ACA signups. The data releases are highly watched given projections of steep enrollment declines from the loss of more generous federal subsidies for plans in 2026.
- Through early January, 22.8 million consumers signed up for ACA coverage, lagging the 23.6 million signups in the same period last year by about 3%. However, given congressional scorekeepers estimate ACA enrollment could plummet 26% this year, the snapshot indicates potentially less drastic enrollment losses than feared.
Dive Insight:
The CMS snapshot, which covers signups through Jan. 3 on the federal platform and through Dec. 27 for state exchanges, is a bright spot for managed care companies with large ACA footprints, such as Centene and Elevance, along with providers worried about a spike in uncompensated care from more Americans going uninsured.
Still, analysts cautioned that coverage selections don’t necessarily equate to paid enrollment. A small percentage of ACA enrollees usually drop off throughout the year after they stop paying premiums — and more did so before enhanced tax credits for ACA plans were enacted in 2021.
How drastically that affects enrollment for 2026 won’t be known until the summer, when data on actual or “effectuated” enrollment is normally released. But attrition could be particularly high this year, given individuals that automatically reenrolled in coverage might choose not to pay their premium or disenroll themselves after seeing steep bills from their insurance carriers.
“In our view, it is too early to call the ACA enrollment declines as ‘less than feared,’” TD Cowen analyst Ryan Langston wrote in a note Tuesday on the CMS snapshot.
In addition, the CMS update doesn’t include information on what types of plans consumers are opting into, or how the overall risk pool has shifted — another big driver of uncertainty for the ACA market in 2026.
Some experts are concerned about an ACA “death spiral” — when insurers raise premiums to account for sicker enrollees, causing healthier individuals to drop out of the exchanges and insurers to raise premiums again to account for sicker enrollees. Eventually, insurers start dropping out as well, and the cycle continues until the market stops functioning.
Still, the snapshot is encouraging for a market that’s bracing itself for significant turmoil this year. More generous federal subsidies credited for driving record enrollment into ACA plans expired at the end of 2025, setting millions of Americans up for painful premium increases.
Without the subsidies, out-of-pocket premiums are set to more than double on average this year, according to estimates from health policy research group KFF. That breaks down to more than $1,000 per person annually, putting coverage out of reach for many — the Congressional Budget Office estimates 2 million people will become uninsured this year as a result of the subsidy loss alone.
Resuscitating the subsidies continues to fuel conversations about healthcare affordability on the Hill, though experts think Congress is unlikely to bring the financial assistance back.
Of the 22.8 million ACA signups, 20 million are those with existing plans while 2.8 million are new to the exchanges. Much of the growth is being driven by large states like Texas and California, though New Mexico and Washington, D.C. have the largest year-over-year increases in enrollment at 20% and 10%, respectively.
However, other states are seeing notable declines, including North Carolina, down 21%, and Ohio, down 19%.
Enrollment for 2026 ACA plans ends on Thursday.
