Dive Brief:
- Almost 23 million Americans signed up for health insurance coverage on the Affordable Care Act exchanges this year, the CMS said on Wednesday. That’s down 5% from last year’s record high, but not the nosedive some market watchers predicted given steep premium increases for ACA plans.
- Some 3.4 million people are new to the marketplaces, while 19.6 million already had ACA coverage and re-enrolled.
- Enrollment trends differ across the country. Much of the volume was driven by Texas alone, where more than 200,000 additional people signed up for coverage in 2026 compared to 2025. Texas led the pack of 9 states and Washington, D.C. that had more residents sign up for ACA plans. The remaining 41 states experienced enrollment declines, with particularly steep drops in North Carolina, down 22%, and Ohio, down 20%.
Dive Insight:
Though ACA enrollment remains open in a handful of states, the CMS data provides a comprehensive look at sign-ups this year, given enrollment ran from Nov. 1 through Jan. 15 on federal and most state exchanges.
For 2026, 15.8 million people enrolled in ACA coverage on the federal Healthcare.gov platform, and 7.2 million enrolled on the state-based exchanges for a total of almost 23 million enrollees, the CMS said.
That’s down from the 24.2 million people who signed up for plans last year, but still above the 21.3 million people who enrolled in 2024 — a record at the time.
Enrollment for 2026 was characterized by fewer new enrollees and softer renewals than the year prior. However, open enrollment was surprisingly robust, given projections of drastic enrollment declines this year.
ACA enrollment fell in most states, with a few key exceptions
More generous federal subsidies credited for driving record sign-ups into ACA plans expired at the end of 2025. Without the tax credits, out-of-pocket premiums more than doubled 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. Estimates vary, but some experts predicted ACA enrollment could fall as sharply as 30% this year as a result.
As such, the 5% drop is a bright spot for managed care companies with large ACA footprints, such as Centene and Elevance, along with hospitals and doctors worried about a spike in uncompensated care from more Americans losing health insurance.
Still, plan selection data doesn’t necessarily translate into actual paid enrollment. Some amount 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.
Elevance, for example, came out of open enrollment for 2026 with ACA members up about 10%, but expects to end the year with a roughly 30% membership decline, according to a J.P. Morgan analysis of the insurer’s fourth quarter comments on Wednesday.
In addition, the CMS update doesn’t include information on what types of plans consumers are opting into — a concern given more Americans appear to be electing for high-deductible bronze plans, which are cheap but come with high out-of-pocket costs that could lead some to put off care.
The CMS also doesn’t share data on how the overall risk pool has shifted, another big driver of uncertainty for the ACA market in 2026.
Worried about higher acuity, health insurers secured big premium increases this year that should protect their bottom lines from a sicker ACA population. Both UnitedHealth and Elevance informed investors this week that they expect to see their ACA margins improve in 2026 despite expected turbulence in the risk pool.
Premium hikes largely represent insurers reacting to increases in underlying medical costs and utilization. Still, major for-profit insurers have emerged as one villain in the ongoing public debate about healthcare affordability raging on Capitol Hill.
Amid the negative attention on payers, UnitedHealth said last week it would send all profits from its ACA business back to its customers this year.
As more Americans struggle to afford healthcare, Democrats in Congress have backed a retroactive extension of the enhanced tax credits, though a deal looks near impossible. Republicans, which control the House and Senate, are largely against an extension, citing the cost to taxpayers and incidences of subsidy fraud in the exchanges.
Still, the party has yet to coalesce around a specific policy platform, despite’s President Donald Trump unveiling his “Great Healthcare Plan” earlier this month.
