ACA marketplace enrollment erosion update

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Last week, Paige Cunningham at Notus reported* that effectuated ACA marketplace enrollment in April was down 21% from end-of-OEP plan selection totals in the 30 states using HealthCare.gov. For all states, April totals were 17% below end-of-OEP, as attrition was far lower in the 20 states that run their own marketplaces. * About half of the SBMs have somewhat mitigated the effect of the expiration of the enhanced subsidies that were funded only through 2025, offering either supplemental state subsidies, strict silver loading, or Basic Health Programs.

As Charles Gaba has highlighted, the end-of-OEP-to-April drop in 2026 was just about double the 2025 drop of 8.8%. Year-over-year, effectuated enrollment in April is down 13.5%, from 22.2 million in 2025 to 19.2 million this year.

One caveat about terminology that will be relevant going forward: Cunningham reports that 21% of end-of-OEP enrollees in the FFM were “dropped from coverage” after failing to pay their first premium. What she actually appears to have reported, though, is a net difference between total plan selections as of the end of OEP and effectuated enrollment in April. Every month, some people drop coverage and others newly obtain it via individually granted Special Enrollment Periods (SEPs), available after various types of life changes, such as losing employer-sponsored coverage. From February of 2022 to August of last year, SEPs were automatically granted to anyone who reported a qualifying income below 150% FPL. Trump’s CMS cut that automatic SEP off as of August 2025 (a change ratified in the Republican monster bill signed on July 4, 2025) - - and consequently, enrollment dropped from April to December last year for the first time since 2020. (In 2021, a pandemic-induced emergency SEP effectively kept enrollment open to all for more than half the year.)

Visiting Delaney: Come on in and buy your caged loved one some candy

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The chairs are provided by volunteers

Forgive me for going off-topic once more to report what I’ve witnessed at Delaney Hall, the immigration detention center in Newark, NJ, operated by Geo Group. I am a regular visitor to one young man detained at Delaney, as well as a member of the volunteer coalition that provides on-site services to visitors —particularly to mothers of babies and small children whose husbands and partners are detained inside.

My wife and I recently published an op-ed about the rich array of support services for detainees’ families provided immediately outside Delaney Hall by a coalition of volunteer organizations and individuals*. That’s a remarkable tale (I’m speaking as a foot soldier, not an organizer), but my focus here is on the experience of visitors when they go inside Delaney. Their treatment under Geo Group procedures is a mixture of systemic abuse and accommodation that I have often mused over. If the U.S. is transitioning to hard-core fascism (jury’s out, IMO). the visitor experience here is a peculiar halfway house.

The visiting set up run by Geo Group at Delaney is truly bizarre-- it has elements not only of cruelty and incredible inefficiency, but also humanity.

First of all, it's communal. When Essex County ran immigrant detention in Trump 1.0, visits were 1-on-1 behind glass. At Delaney, visits are in what feels like a giant lunchroom, with sometimes over 100 voices reverberating. There are five or six rows of long tables. Detainees sit on benches on one side; visitors face them. Lately the room has sometimes been packed, so that visitors are almost hip to hip (there can be up to four visitors per detainee).

CSR forgone: Long- and short-term changes in the ACA marketplace

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When considering how the most seismic changes in the ACA marketplace’s 13-year history have shaken out, it’s important to keep in mind that the market mainly serves very low-income people. Consider*:

• 64% of all marketplace enrollees in 2026 had income in the 100-200% FPL range. In the U.S. population at large, just 15% were in that income range as of 2024.

• 54% of all marketplace enrollment (12,487,037) in 2026 is in ten states that have refused to enact the ACA Medicaid expansion, where eligibility for marketplace subsidies begins at 100% FPL. In expansion states, Medicaid is available to all adult citizens and qualified noncitizens with income up to 138% FPL.

• More than half of enrollment in nonexpansion states (6,543,435) is in an income bracket (100-138% of the Federal Poverty Level, or FPL) that would qualify those enrollees for Medicaid in expansion states. Those should-be-in-Medicaid enrollees account for 28% of all marketplace enrollment.

• In 2026, 83% of silver plan enrollees nationally had income in the 100-200% FPL range, qualifying them for strong Cost Sharing Reduction (CSR) that raises the actuarial value (AV) of a silver plan to 94% (at incomes up to 150% FPL) or 87% (at income from 150-200% FPL). Nationally, the average AV obtained by silver plan enrollees was 88.6%, justifying the presumption now enforced by several states that silver plans should be priced at a roughly platinum level (90% AV), well above gold (80% AV).

With that low-income skew in mind, I’d like to examine both long-term enrollment trends and shifts in metal selection in 2026, the latter driven mainly (presumably) by expiration of the enhanced ARPA subsidies.

Trends include:

Republicans poised to steal gold from Texans

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To fund Trump’s depraved, immoral and illegal assault on Iran, Axios reports that a Texas sage is proposing a fresh cut to ACA marketplace premiums:

House Budget Committee Chairman Jodey Arrington (R-Texas) is reviving an idea that was considered last year to fund Affordable Care Act payments known as cost-sharing reductions [CSR].

• The Congressional Budget Office previously found the move would lower overall benchmark ACA premiums by 11% but result in 300,000 more uninsured people.

• It would have the effect of cutting the subsidy amount that some enrollees receive, thereby increasing out-of-pocket premium costs, while saving the government over $30 billion.

That proposal would kill silver loading, which would have the most profound effects in Arrington’s Texas, where the pricing of silver plans at platinum levels mandated by statute renders gold plans far cheaper than silver plans and makes free bronze coverage available to almost all enrollees. Before Republicans in Congress seek to end the practice, the 1.7 million Texans in gold plans and likely 800,000-plus in zero-premium bronze plans might want a word.

ACA Marketplace 2026: The downshift to bronze

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Charles Gaba, via a trick that presents itself to the highly motivated, has got hold of the 2026 Public Use Files (PUFs) for the ACA marketplace before they’re officially announced and has parsed them 26 ways. He’s also kindly shared the trick, and so the file.

I want to continue my focus on the degradation of coverage — that is, the shift to lower metal levels, and in particular, the shift away from silver among those eligible for strong Cost Sharing Reduction (CSR), which raises the actuarial value of a silver plan from a baseline of 70% to 94% (at incomes up to 150% of the Federal Poverty level) or 87% (for those in the 150-200% FPL) range.*

For starters, here is the metal level breakdown for all states in 2025 vs. 2026.

Accelerating a multi-year trend, silver selection fell sharply. a shift modestly offset by an increase in gold selection, as three states (Washington, Arkansas, Illinois) newly implemented strict silver loading in 2026, rendering gold plans less expensive than silver (in Illinois and Arkansas, 31% of enrollees selected gold plans, and in Washington, 51% selected gold).

Triage for U.S. healthcare: Families USA's Stop the Bleed campaign

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In the United States today, as rising healthcare costs for individuals and government alike approach a crisis point, major systemic change enacted by legislation feels utopian. Behemoths stalk the healthcare landscape: Mega-insurers control major PBMs, large numbers of physician practices, and tech tools to maximize billing; hospital systems dominate their regions; pharmaceuticals maximize pricing power over fractured payers; private equity firms roll up major physician specialist practices within target markets and dominate target services like hospice and dialysis.

These powerful actors deploy our corrupt campaign financing rules to deter elected officials from both parties from enacting legislation that would fundamentally threaten their current revenue sources. A single-payer system, or a strong public option available to all, or a national system of all-payer rate-setting, are not likely to happen this side of revolution (including, on the hopeful side, political revolution).

In tacit acknowledgment of those facts, Families USA has launched Stop the Bleed — almost literally a triage campaign to provide some cost relief to the people of this country. The campaign invites healthcare advocates — and anyone who wants to sign up — to ask candidates for electoral office from both parties and at any level what they propose to do to control healthcare costs.

In GetCoveredNJ, a shift toward bronze plans in 2026

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This year's NJ marketplace has feet of bronze

GetCoveredNJ, New Jersey’s state ACA marketplace, has released its final enrollment snapshot for OEP 2026. Enrollment is down less than 1% from OEP 2025, but attrition when people have to make their first premium payments — and, if they get that far, sustain higher payments year-long — will probably drop average monthly enrollment well below the 2025 level. * In particular, the 211,289 renewing enrollees who passively auto-re-enrolled may react to sticker shock. (Conversely, a very sharp spike in active re-enrollments, from 85,177 in 2025 to 219,933 in 2026, points to a large potential well of resilience — people who noted the premium spikes and made a conscious choice.)

As the enrollment report emphasizes, premiums rose sharply for most enrollees in 2026, whether or not they lost subsidy eligibility. In 2025, 44% of all enrollees had paid less than $10/month in premiums; this year, just 10% will. Last year, 28% of enrollees paid more than $100/month; this year, 44% have crossed that threshold. This year, 18% of enrollees obtained no federal subsidy ; last year, just 9% went without APTC. (A third of those who are ineligible for federal subsidies obtained smaller state supplemental subsidies, available at incomes up to 600% FPL.) See Gaba for a finer-grained breakdown of net-of-subsidy premiums paid.

I want to focus here on coverage degradation in 2026 — a down-shifting in metal level. In New Jersey, that means almost entirely a switch from silver plans to bronze, because in NJ, gold plans are effectively unaffordable, chosen by just 1% of enrollees in 2025 and 2026 alike. The Jersey marketplace has always been dominated by silver plans, but in 2026 silver selection dropped to 74.1%, down from 83.3% in 2025.

CMS steers ACA marketplace enrollees toward the Scylla of catastrophic plans and the Charybdis of non-network plans

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Between CMS's Scylla and Charybdis 

There is a throughline in Republican proposals, both legislative and regulatory, to “reform” health insurance, particularly in the ACA marketplace. Consistently, Republicans propose to reduce premiums paid by government and (sometimes) enrollees by

• increasing out-of-pocket exposure;

• narrowing provider networks; and

• increasing risk and uncertainty for enrollees.

CMS’s just-published 2027 Notice of Benefit and Payment Parameters (NBPP) for the ACA marketplace, a multi-part rule published annually, advances these goals on multiple fronts. The NBPP would expand access to catastrophic plans (available only without subsidy); degrade actuarial value in catastrophic and bronze plans by allowing them to add 30% to the highest allowable annual out-of-pocket maximum (to an eye-watering $15,400 per individual in 2027); deliberately draw healthier enrollees into the catastrophic market, worsening the main ACA risk pool; weaken network adequacy requirements; financially penalize states for incorporating their own coverage mandates in Essential Health Benefits (EHBJ) standards; and allow QHP certification of non-network plans.

I want to focus here on the certification of non-network plans, because it is a first swipe at the longstanding Republican goal of directing premium subsidies to plans reminiscent of the pre-ACA marketplace. In this case, CMS proposes to expose marketplace enrollees to out-of-pocket costs with no effective cap and to the balance billing that’s now mostly prohibited against enrollees in minimum essential coverage provided by marketplace or employer-sponsored plans.

How much will average monthly enrollment drop in the ACA marketplace in 2026?

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Downhill slope: gradual or steep?

While the ACA marketplace’s Open Enrollment Period (OEP) for 2026 is wrapping up with a relatively modest drop of about 5% from OEP 2025, marketplace observers expect the losses to deepen as the year progresses. That’s primarily for two reasons: 1) most subsidized enrollees are facing steep premium increases because the enhanced subsidies funded through 2025 have not been extended, and 2) a June 2025 CMS rule effectively ratified in HR1, the Republican megabill enacted last July, ended year-round enrollment for low-income enrollees.

The most complete measure of enrollment in a given year is average monthly enrollment (AME), which takes into account both retention and the conditions under which people enroll when OEP is finished. The gap between enrollment* totals as of the end of OEP and AME has varied considerably over the marketplace’s 13-year existence. To scope out the likely range of enrollment losses through the full 2026 plan year, Charles Gaba has tabulated the OEP-AME gap for every plan year through 2025.

The gap shrank during the first Trump administration, both because enrollment barriers the administration threw up (shortened OEP, sharply reduced funding for enrollment assistance and marketing) weeded out less motivated enrollees, and because the advent of silver loading after Trump cut off direct CSR payments to insurers made zero-premium coverage newly available to millions, and people don’t tend to drop zero-premium coverage. The gap shrank further during the Biden years, as the enhanced premium subsidies enacted in March 2021 as part of the American Rescue Plan Act (ARPA) further expanded the availability of zero-premium (and low-premium) coverage, and as year-round enrollment for enrollees with income under 150% FPL was implemented in early 2022. (In 2025, 47% of all enrollment was at incomes below the 150% FPL threshold.) The Medicaid unwinding — that is, the resumption of Medicaid redeterminations and disenrollments in spring 2023 after a 3-year pandemic induced moratorium — reduced the OEP-AME gap to near-nothing in 2023 and 2024, as millions transitioned from Medicaid to the marketplace.

---

Gaba further uses the OEP/AME ratios in the pre-ARPA years to project a range of possible enrollment losses in 2026:

Of course we can’t know whether enrollment losses will be within this range. There are reasons to believe that attrition will exceed the 2016 peak (excluding 2014, when the marketplace was immature), but there are also mitigating factors. Let’s look at both sides of the equation.

Factors that may trigger major attrition

1. Unprecedented net-of-subsidy premium hikes. Prior to OEP 2026, marketplace premium subsidies have never lost value (or rather, never lost more than a few of tenths of a percentage point, as the “applicable percentages” of income required for a benchmark silver plan at each income level were adjusted modestly for inflation in the years prior to enactment of the enhanced subsidies, and again in 2026). By KFF’s estimate, in 2026, net-of-subsidy premiums for a benchmark silver plan rose by an average of114% for the 92% of 2025 enrollees who were subsidy-eligible.

2. Increased auto-reenrollment. In HealthCare.gov states, passive auto-reenrollment spiked from 30% of reenrollments in 2024 to 46% in 2025 (see public use files here). Many of those auto reenrollees may be unaware of the degree to which their premiums have spiked in 2026 (not only because of reduced subsidies, but because of annual shifts in the benchmark plan and its premium). If many of the auto-reenrollees have incomes below 150% FPL (as did more than half of enrollees in HealthCare.gov states in 2025), they will also have lost the ability to switch to a less expensive plan when they discover the premium spike. Which brings back to…

3. No more monthly SEPs at low incomes. In February 2022, the Biden administration implemented a monthly Special Enrollment Period (SEP) for enrollees with income up to 150% FPL, for whom the enhanced subsidies created in March 2021 had rendered benchmark silver coverage free. Year-round SEPs have given average monthly enrollment a major boost, as Gaba’s tables show (2021 enrollment was boosted by a six-month SEP for all comers in the wake of the enhanced subsidies enacted in March of that year). As noted above, the year-round SEP also enabled passive reenrollees stung by an unexpected premium hike to switch into a less expensive plan. The current Trump administration ended the monthly SEP by administrative rule, effective last August, and the HR1 megabill effectively codified the rule by making subsidies unavailable for SEPs granted on the basis of low income.

4. SEP verification. CMS’s Program Integrity Rule finalized in June 2025 tightened verification requirements for life changes (such as loss of employment) that trigger a SEP, requiring verification for 75% of SEPs beginning in 2026.

Factors that may mitigate attrition

1. Silver loading. After Trump abruptly cut off direct reimbursement of insurers for the Cost Sharing Reduction (CSR) subsidies that attach to silver plans for low-income enrollees, most states allowed or encouraged insurers to price CSR directly into silver plans only. That raised benchmark premiums and therefore subsidies and raised the premiums for silver plans relative to bronze and gold plans, as CSR makes silver plans roughly platinum-equivalent for enrollees with income up to 200% FPL (i.e., for most silver plan enrollees). Silver loading made zero-premium bronze plans available to millions more enrollees than previously, boosting not only enrollment (by perhaps 5% in 2019) but retention. Logically speaking, silver loading should have made gold plans consistently cheaper than silver plans, as CMS noted in a December 2015 memo. While that did not happen, as insurers have various incentives to underprice silver plans, over time an increasing number of states have mandated more strict silver loading - -and in some cases, most notably in Texas — required insurers to price silver plans as if they are platinum (Arkansas, Illinois and Washington did this in advance of OEP 2026). Silver loading’s impact on gold premiums is consequently more intense in 2026 than in Trump 1.0 years — when, per Gaba’s table above, those effects probably had a major role in reducing attrition. In 2018, the average lowest-cost gold premium nationally was 109% of the benchmark (second cheapest) silver premium, whereas in 2026, lowest-cost gold on average is 98% of the benchmark. Cheap gold plans will have a particularly strong effect in Texas, where $0 premium gold plans will be available to about 2.5 million enrollees with income under 150% FPL, and to many older enrollees with income near 200% FPL. Zero premium bronze plans will be available to far more enrollees than that.

2. Broker participation and public awareness. In the pre-ARPA era, when marketplace AME was stuck at around 10 million, the marketplace was hampered not only by subsidies that many found inadequate but also by widespread ignorance of marketplace offerings. For years, enrollment assistors told me that many people thought the program had been repealed (even in 2024), and Republican hostility to “Obamacare” remained a factor. While the first Trump administration did gut funding for nonprofit enrollment assistance, however, it also encouraged and marketed broker participation and continued the development of commercial e-broker platforms (a.k.a. enhanced direct enrollment, or EDE, platforms) that make brokers’ jobs much easier. As enrollment soared after the ARPA subsidies were implemented, so did broker participation, rising from 49,000 in 2018 to 83,000 in early 2024. While brokers’ too-easy access to enrollees’ accounts via EDE platforms sparked a plague of fraud and low-quality brokerage, broker outreach plainly reached deep into low-income areas, particularly in states that had refused to expand Medicaid, where marketplace subsidy eligibility begins at incomes of 100% FPL, as opposed to 138% FPL in expansion states (and again, CSR-enhanced silver coverage was available for free at incomes up to 150% FPL). In addition to providing sometimes-expert help, brokers have a strong motive to keep clients enrolled, and they have likely steered many clients into lower-premium plans to mitigate the impact of average net-of-subsidy premium hikes. In 2024, about 80% of enrollments in HealthCare.gov states were broker-assisted.

3. Habit. Coverage is tough to lose, and about 12 million more people signed up for marketplace coverage in OEP 2025 than in OEP 2020. While many may drop coverage as higher premiums bite — or as they try to use plans with $8,000 deductibles — many more will do what they can stay covered.

So there you have it. I’m not going to venture a prediction. We’ll have a better sense of what AME is likely to look like when the first effectuated enrollment snapshot, showing paid-up enrollment as of February, is published in June or July. But that snapshot will not show the coverage drop for re-enrollees who have not paid their first premium, as enrollees are generally granted a 3-month grace period. CMS is currently publishing effectuated enrollment with a three-month lag as part of its monthly snapshots of Medicaid/CHIP enrollment, so we may have a clearer picture by June or July (a half-year effectuated enrollment snapshot usually comes out in the fall). Full AME for 2026 won’t be published until mid-2027, if current practice holds. But who knows where this country — and the marketplace — will be by then.

P.S. Any measure of coverage losses in the post-ARPA era (if it lasts more than a few weeks or months) should incorporate a loss in average actuarial value, as low-income enrollees exchange high-CSR silver for bronze or even gold plans. See my post on a proposed measure: Total AV for the whole marketplace. 

- - -

*Technically, “plan selections” tallied as of the end of OEP are not “enrollments,” as some will never be effectuated.

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Health Action 2026: Defense, and a glimmer of new vision

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Families USA launches a campaign

The mood was grim but determined at Families USA’s Health Action 2026 conference in D.C. last week. Broadly speaking, the focus was dual: mitigating the harm wrought by Republicans’ $1 trillion-plus cuts to Medicaid and the ACA marketplace (and RFK Jr.’s perversion of federal public health agencies), and looking forward toward a positive agenda for making healthcare affordable for all Americans.

Mitigation is largely about slow boring on hard boards: state agencies riding herd on the managed care organization (MCOs) that run most of their Medicaid programs, and advocacy groups riding herd on state agencies to drive that accountability.

The forward-looking agenda was not about ultimate visions for the U.S. healthcare system, such as single-payer or “Medicare for all who want it.” Rather, the focus, mainly in the plenary session “Building the Health Care System We Deserve,” was on spotlighting the extent to which the drive to maximize profit permeates and corrupts all main sectors of the healthcare system — hospital systems and physician practices, insurance and pharma.

That spotlight was synced with a campaign Families USA kicked off with the conference, Stop the Bleed, which aims to challenge every candidate for office in 2026 to explain what they would do to contain healthcare costs — not just what individuals pay, but what all payers collectively pay.