Dive Brief:
- Fewer insurers are participating in the Affordable Care Act marketplaces as the exchanges are roiled by federal policy turmoil and rising costs, according to an analysis published last week by KFF.
- The average number of issuers offering plans on the marketplaces has fallen from a record high of 9.6 per state last year to just nine in 2026, the health policy researcher found.
- Three in 10 U.S. counties have fewer ACA insurers in 2026. In 165 counties, only one insurer is offering plans on the exchange, compared with 93 counties last year.
Dive Insight:
The decrease marks the first time the average number of insurers in the ACA marketplaces has fallen since 2018, according to KFF.
One contributor to the decline is the falling number of Americans seeking coverage, the health policy researcher said. More generous financial assistance for people buying insurance on the ACA marketplaces expired at the end of last year after Republicans in Congress refused to extend it.
The lapse has caused premiums for the plans to increase, pushing many Americans to drop their coverage or search for cheaper plans. Enrollment in the ACA exchanges has declined by more than 1 million people since last year, and more beneficiaries are expected to drop off over the course of 2026 as they fail to pay the higher premiums.
Overall, average effectuated enrollment, or the amount of people who pay their premiums and maintain coverage, could decline by around 5 million people from 2025 to 2026, according to KFF. And as Americans leave the exchanges, more insurers could decide to follow suit, worried about their profit margins from covering a smaller and likely sicker population.
Some insurers have already left. CVS-owned Aetna stopped participating in the exchanges for 2026, and Cigna plans to exit next year. Smaller insurers like Providence Health Plan and PacificSource Health Plans are dropping the ACA exchanges in 2027 too.
Despite the flurry of exits, the number of ACA insurers on offer differs across states, according to KFF.
Eighteen states saw their ACA carriers decline from 2025 to 2026. Illinois and Michigan saw the greatest decrease in the number of carriers, with three fewer insurers participating in 2026.
Four states — Alabama, Iowa, Louisiana and Washington — had a net increase of one insurer.
Even if a payer continues operating in a state, insurers may still change their footprints within counties. Counties in Wisconsin had the highest number of insurer exits, and some counties in North Carolina and Michigan also experienced significant decreases, according to KFF.
