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.

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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. 

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

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A new measure of pending marketplace degradation

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Will Plan Year 2025 forever be Obamacare's Babe Ruth? 

Charles Gaba has issued a timely warning that most of the enrollment loss in the ACA marketplace this year, resulting from expiration (so far) of the enhanced premium subsidies funded only through 2025, will only be evident after CMS releases its first snapshot of effectuated coverage — that is, paid-for coverage. Thanks to auto re-enrollment, enrollment losses will look relatively slight (perhaps minus 1 million) as of the end of the Open Enrollment Period.

Republicans will make hay of this — claiming, as CMS did, that the subsidy reduction is not so catastrophic for the 93% of enrollees subsidized in 2025 who will remain subsidy eligible in 2026. And CMS’s annual snapshot of coverage effectuated as of Feb. 1 typically doesn’t appear until June or July. At that politically distant point, much more of the fallout from expiration of the enhanced subsidies will become visible.

In 2024 and 2025, early effectuated coverage exceeded 95% of end-of-OEP enrollment, whereas in 2016, it was just 85%. Retention improved during the first Trump administration, probably for reasons including 1) a shortened Open Enrollment period and cuts to funding for enrollment assistance and outreach, which likely discouraged more marginal enrollees from enrolling at all, and 2) Trump’s cutoff in October 2017 of direct reimbursement of insurers for the Cost Sharing Reduction (CSR) subsidies that attach to silver plans at low incomes, which triggered silver loading (the pricing of CSR into silver plan premiums) and increased the number of enrollees paying zero or very low premium. Retention increased further after the enhanced subsidies enacted by the American Rescue Plan Action March 2021 made zero-premium coverage much more widely available — to the point where, in 2025, about a third of all enrollees paid zero premium.

There’s reason to believe that massive sticker shock when the first 2026 premium bills arrive — with subsidized premiums for a benchmark silver plan more than doubling on average from 2025 to 2026 — will drive the ratio between OEP enrollment and February effectuated enrollment back to Obama-era levels this year, or even lower. Further, since Republicans have terminated year-round enrollment for enrollees with income below 150% FPL, average monthly enrollment in 2026 will drop even further compared to 2025. That change won’t be evident until mid-year 2027.

Read Gaba on this. He’s sharp on the political ironies (with advocates of the enhanced subsidies now echoing Republicans’ 2014 cry of “but how many have paid?” as the ACA’s first enrollment period wound down), and he roughs out credible estimates, roughly matching CBO’s, of enrollment losses in 2026 as reflected in average monthly enrollment (about 4 million). What I want to do here is consider another important effect of reduced subsidies: The likelihood that many who remain enrolled will downgrade their coverage to reduce their premiums. How might we measure the combined effects of increased uninsurance and increased under-insurance?

To get a grip on any future degradation of coverage obtained in the marketplace, we can use actuarial value (AV) — in combination with effectuated enrollment. AV is the percentage of the average enrollee’s costs a plan is designed to cover, calculated according to a formula created by CMS.*

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Average weighted AV in the entire national marketplace has been stable over the years at 78-79% (compared to about 84% in employer-sponsored coverage), though the factors determining the average have been quite volatile. More on that stability/volatility below. If the enhanced subsidies are not renewed, I believe average AV as well as total enrollment will drop in 2026 and years following. To get a sense of the effects of dropped coverage and degraded coverage, I propose a measure something like “OPS” in baseball — a combination of on-base percentage and slugging percentage. The measure would simply be “Total AV” — total enrollment times average weighted actuarial value. The best measure of total enrollment, although it entails an 18-month data lag (under current practice), would be average monthly enrollment. An alternative measure, available roughly six months after the end of each OEP, would be early effectuated enrollment (as of February).

In 2025, we have a figure for average monthly enrollment through September**: 22.4 million (22,356,622). As Republicans terminated year-round enrollment at low incomes (implemented by the Biden administration) as of August, there will probably be a slight drop in the full year total, when available, to perhaps 22.3 million. Average weighted AV was 79.0% (Total AV calculations require a bit of extrapolation, outlined in a note at bottom, from the Public Use Files published by CMS). Total AV for the marketplace in 2025 will thus be about 18.4 million — probably a permanent all-time high, if the enhanced subsidies are not restored.

Taking expected increased attrition into account, Gaba estimates that average monthly enrollment will drop to about 18.5 million in 2026. That’s a 17% drop from 22.3 million in 2025. If weighted average AV drops, say, from 79% to 75%, Total AV in 2026 will be 13.9 million— a 24% drop. That’s a fuller measure of what may be lost.

Average weighted AV: Stable in aggregate, volatile in composition

As to the shifting composition of average weighted AV in the ACA marketplace over the years: The chief source of high-AV coverage in the marketplace is the Cost Sharing Reduction (CSR) that attaches to silver plans at low incomes, raising a silver plan’s AV to 94% at incomes up to 150% of the Federal Poverty Level and to 87% at incomes in the 150-200% FPL range — compared to 60% for bronze and 80% for gold. Over the years, silver plan selection at low incomes (those eligible for strong CSR) has eroded steadily, but the percentage of enrollees with income below 200% FPL has risen sharply. (A weak CSR is available in the 200-250% FPL bracket, raising AV to 73% . AV for silver plans without CSR is 70%.)

First, look at the rate of silver selection at the two highest CSR levels from 2017-2025. This is only in HealthCare.gov states, as in early years CMS data for state-based marketplaces was much less complete. Over this period, the number of states using the federal exchange dropped from 39 to 30. At the same time, all states that have refused to enact the ACA Medicaid expansion (excepting Idaho until 2020) used the federal exchange throughout these years, ensuring that enrollment in the 100-150% FPL income bracket has always been concentrated in HealthCare.gov states (In 2025, when just 30 states used HealthCare.gov, 85% of enrollees at 100-150% FPL were in Healthcare.gov states).

While silver selection at incomes where strong CSR (94% or 87% AV) is available has dropped, the percentage of enrollees at incomes below 200% FPL has risen steadily since 2019 (the first year in which CMS provided income breakouts for all states).

The percentage of all enrollees who obtained CSR hit an all-time high in 2017 at 57%, dipped to 53% in 2018 (the first year when silver loading went into effect), and was 53% in 2025. But not all CSR is created equal, and in the silver loading era, silver selection in the 200-250% FPL bracket, where CSR raises AV to just 73%, fell off a cliff. In 2017, in HealthCare.gov states, 16% of silver selection at CSR-eligible incomes was in the 200-250% FPL bracket; in 2025, that percentage was down to 3.5%. Conversely, in 2025 78% CSR enrollment was in the 100-150% FPL bracket, compared 52% in 2017. In 2025, in HealthCare.gov states, 41% of all enrollees — 7 million out of 17.1 million — obtained CSR with a 94% AV.

A word about enrollment at income below 100% FPL, the income threshold below which marketplace subsidies are unavailable for citizens. CMS did not break out this income bracket until 2022. In 2025, there were 548,650 enrollees in the under-100% FPL bracket, 2.2% of all enrollment. Most of them were lawfully present noncitizens subject to the “5-year bar” to Medicaid eligibility to which U.S. law subjects noncitizens. The ACA stipulates that immigrants subject to the 5-year bar are subsidy-eligible in the marketplace even if their income is below 100% FPL. But the Republicans’ vile megabill enacted this summer stripped out this eligibility as of Jan. 1, 2026. CBO estimates that about 300,000 immigrants will lose coverage as a result — and most of them were probably enrolled in high-CSR silver. That’s one more ding to average AV (as well as enrollment) in 2026 and years following, even if the enhanced subsidies are extended.

The other major change in the distribution of AV over the years derives from silver loading — the pricing of CSR directly into silver plan premiums, adhered to in varying degrees in different states and rating areas, or by different insurers within states and rating areas. Because ACA premium subsidies are designed so that enrollees pay a fixed percentage of income (varying by income bracket) for the benchmark (second-cheapest) silver plan, when silver premiums rise, so do subsidies, and so do “spreads” between the benchmark silver plan and cheaper plans — e.g., most bronze plans, and in some states, many or most gold plans. Since insurers tend for competitive reasons to underprice silver plans (as silver remains the dominant metal level, since most enrollees qualify for strong CSR), an increasing number of states are mandating that insurers price plans in strict proportion to actuarial value. Since silver plans, enhanced by CSR for most enrollees, have higher AV than gold plans, gold plans should be cheaper than silver - -and in 20 states in 2026, lowest-cost gold plans are on average priced at premiums below that of the silver benchmark.

Weak or strong silver loading has been in place in almost all states since 2018, and as a result, silver plan selection has collapsed at incomes over 200% FPL (where CSR is weak or unavailable) as well as eroding at incomes under 200% FPL. Note above that gold plan selection as well as bronze plan selection has increased at low incomes. Much of the gold selection increase is concentrated in Texas, where gold plans are far cheaper than silver. In 2025, almost 900,000 Texas enrollees with income under 200% FPL enrolled in gold plans. That’s about 6% of all enrollees with income under 200% FPL nationwide.

Low-income enrollees who select gold plans are giving up AV, often in exchange for a reduced premium (e.g., to obtain coverage from an insurer whose silver plan is priced above benchmark). The difference in AV is reflected most dramatically in the annual out of pocket maximum .By statute, out-of-pocket maximums are capped at a much lower level for CSR-enhanced silver plans available to those with income under 200% FPL than for all other plans, including gold. In 2026, the highest allowable OOP max for silver plans at incomes up to 200% FPL is $3,500, compared to $10,600 for other metal levels. For enrollees with income below 150% FPL, silver OOP maxes are usually far lower than $3,500, averaging $1,738 in 2026, according to KFF.

At incomes over 200% FPL, the window in which the premium difference between silver plans and bronze plans is worth the higher AV provided by silver plans is very narrow — and again, in many states, at least some gold plans are cheaper than benchmark silver. Silver selection at incomes over 200% FPL has appropriately collapsed. Here is the breakout in HealthCare.gov states:

With respect to average weighted AV, the increase in gold selection in this income bracket only partly offsets the larger increase in bronze selection. But again, inflated silver premiums more often than not make bronze a better value than silver at incomes over 200% FPL.

Why enrollment has doubled and silver plan selection has diminished

The story of why enrollment surged after ARPA was enacted in March 2021 is in one sense straightforward: ARPA made high-CSR coverage free to enrollees with income up to 150% FPL, increased premium subsidies in every income bracket, and lifted the income cap on subsidy eligibility. But the story is somewhat complicated, for better and worse, by surging broker participation in those years. The number of brokers registered with HealthCare.gov rose from 49,000 in 2018 to 83,000 as of OEP for 2024. Since Americans remain persistently ignorant about what’s available in the marketplace until they need it, increased broker outreach was probably key to the doubling of enrollment in the post-ARPA era. At the same time, broker fraud also metastasized around 2023-2024. A CMS crackdown and rule-tightening has probably reduced such fraud but has not yet quelled it, to judge from broker discussion sites I tune into. Brokers enrolled probably some hundreds of thousands of people without their knowledge or consent — the totals are still unknown — and engaged in unauthorized plan switching — sometimes multiple times — for hundreds of thousands more. (The switching may have slightly pushed average AV down slightly, as fraudster brokers looked for zero-premium plans to switch enrollees into, and most of those would be bronze plans.)

The story of why silver selection has eroded at incomes under 200% FPL is more complicated. As more low-income enrollees have poured into the marketplace in the enhanced subsidy era, some may simply make mistakes. The number of available plans in each rating area has proliferated; the average enrollee is confronted with more than 100 choices. Most enrollments are broker-assisted, and there is a fair amount of low-quality and sometimes corrupt brokerage, though I know of no source or means to assess broker quality norms (a good broker is priceless, given our ridiculously complex marketplace, and there are plenty of good ones). At the same time, I have delved more than once into the probably-increasing incidence of enrollees choosing lower-AV coverage with eyes wide open, in order to obtain coverage from a plan with a more robust provider network or a formulary that covers the enrollee’s drugs. Competition has pushed the marketplace toward narrow networks, especially at the lowest premiums at each metal level, and that has probably induced more enrollees to trade AV for network or formulary quality.

In any case, expiration of the enhanced subsidies is likely to accelerate the erosion of CSR takeup. An option to take some or all of the premium subsidy as an HSA would of course further erode AV, trading first-dollar coverage for increased exposure to high out-of-pocket costs. Total AV for the marketplace is therefore likely to erode even faster than total enrollment if subsidies remain at current levels.

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*AV is in one sense a misleading measure, in that the average is skewed by the small percentage of enrollees in any plan who incur very high costs (capped for the enrollee by the out-of-pocket maximum, which this year can be as high as $10,600). If your plan has an AV of 60% and covers essentially no costs before, say, an $8,500 deductible, but you’re in an accident and incur $100,000 in medical costs, if the out-of-pocket maximum is $10,000, 90% of your costs are covered. For many other enrollees in such a plan, AV may be effectively zero, even if they spend thousands of dollars out of pocket. That said, AV is a uniform measure that does indicate the relative value from year to year of marketplace coverage.

**See Gaba, who posts a table combining 6 months of effectuated enrollment for 2025 available here (find “January-July effectuated enrollment tables” for 2025) with August and September estimates provided in CMS’s monthly Medicaid and CHIP enrollment snapshots.

A note on average weighted AV calculations. The marketplace Public Use Files for 2022 through 2025 break out enrollment at each CSR level for HealthCare.gov states but not for all states. As a proxy, I used the breakouts of metal level enrollment by income in the “State, Metal Level and Enrollment Status” PUF, taking silver totals as a proxy for CSR levels, subtracting the difference between total CSR enrollment (provided for all states) and total silver enrollment at incomes from 0-200% FPL proportionately from each CSR bracket.
     For 2017, I had to get a bit more creative, as metal level selection by income was broken out only for HealthCare.gov states, though the PUF does show total silver enrollment in both HealthCare.gov states and SBM states. To estimate the distribution of silver selection by income in SBM states, I used the “SBM-FPs” — nominal state marketplaces using the federal exchange — as a proxy, since all four of those states had expanded Medicaid. I then calculated an average silver AV for HealthCare.gov states (84.6%) and SBM states (80.7%) and used those averages for total silver enrollment in each of the two categories.

Edited 1/9/25 -- including correction of a typo regarding avg. monthly enrollment in 2025 (estimated at 22.3 million, not 23.3 million).

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Retention in ACA marketplace continues to improve

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CMS just dropped its Effectuated Enrollment Early 2023 Snapshot and Full Year 2022 Average — a document I’ve been eagerly awaiting.

To my eye, the main takeaway is that in the second full year of enrollment after the American Rescue Plan Act (ARPA) boosted ACA marketplace subsidies, retention and off-season enrollment remain impressive. That’s reflected in average monthly enrollment for 2022 as well as early effectuated enrollment for 2023.

Year-over-year, from 2022 to 2023, early effectuated enrollment (enrollment as of the first month when premiums were due for all who selected plans during the Open Enrollment Period, or OEP) increased by 13.4% — more than the 12.7% year-over-year increase in plan selections during OEP, as the percentage of OEP plan selectors who effectuated enrollment reached an all-time high. That increase in retention of OEP signups continues a long-term trend.

The table below shows the ratios of early effectuated enrollment and average monthly enrollment to OEP signups since 2016.

ACA Marketplace Retention, 2016-2023 

Sources: CMS Public Use Files and Effectuated Enrollment Snapshots

Total individual market enrollment in health insurance may (finally) be at an all-time ACA-era high

Please see a 2023 update at https://xpostfactoid.substack.com/p/aca-effectuated-enrollment-in-2023 

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In June 2021, I wondered, will attrition in the ACA marketplace go negative?

Until the pandemic struck, enrollment attrition throughout the coverage year in the ACA marketplace was an established norm. Every year, effectuated enrollment (i.e. paid-up enrollment) as of the first month after the end of Open Enrollment (OE) was between 6% and 15% lower than the "plan selection" total as of the end of OE. From February through December, enrollment would downtick by 600-800,000....

This year, we're in a different world. The Biden administration opened an emergency SEP in HealthCare.gov on February 15, extending August 15, and the state exchanges followed suit, with some variations. Then the American Rescue Plan, signed into law on March 11, provided a massive subsidy boost through 2022, with the new subsidies appearing live on HealthCare.gov on April 1, and in state exchanges pretty shortly thereafter.

Well, the results are in, courtesy of CMS's early effectuated enrollment snapshot for 2022, which includes average monthly enrollment and month-by-month enrollment totals for the year prior.* And the answer is: almost! Or, in a sense, yes!  

Average monthly enrollment in 2021 came to 97.8% of  total plan selections as of the end of the year's Open Enrollment Period -- and to 106.3% of the early effectuated enrollment total reported as of February 2021.** 

ACA marketplace enrollment retention, 2016-2022 

Year	End of OE	Post-OE effectuated	Early effectuated/OE	Average monthly	Avg. monthly/OE
2016	12,681,874	10,828,894	85.4%	10,007,113	78.9%
2017	12,216,003	10,526,942	86.2%	9,763,076	79.9%
2018	11,750,175	10,515,192	89.5%	9,895,197	84.2%
2019	11,444,141	10,433,850	91.2%	9,810,613	85.7%
2020	11,409,447	10,592,901	92.8%	10,408,892	91.2%
2021	12,004,365	11,034,220	91.9%	11,734,931	97.8%
2022	14,511,077	13,807,669	95.2%

Sources: CMS state-level public use files and effectuated enrollment snapshots

If HHS cuts back short-term plans, they'd best be sure that the ARP subsidy boosts are extended

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 Alice Ollstein of Politico relays:

[HHS Secretary] Becerra says he's "in the midst of rulemaking" to crack down on skimpy health insurance plans that Democratic lawmakers and activists call "junk plans." No word on when that rule could come out, but it would undo the Trump admin's rule opening the door to more of those plans.

The "skimpy health plans" are so-called short-term limited duration (STLD) plans promoted and facilitated by the Trump administration. STLD plans are not ACA-compliant: they don't have to cover the ACA-mandated Essential Health Benefits (and usually don't provide coverage of most prescription drugs), and they are medically underwritten, meaning that applicants with pre-existing conditions can be charged more, denied coverage altogether, or offered coverage with the pre-existing condition excluded.

ACA marketplace enrollment in 2020 exceeded the 2016 peak (on-exchange)

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Every June, the first "effectuated enrollment snapshot" of the ACA marketplace for February includes month-by-month and average monthly enrollment for the previous year.

Though I had been eagerly awaiting this year's snapshot, having inferred last December that marketplace enrollment in June 2020 was probably at all-time mid-year high, I missed its release on June 5. But it's out, and it's official: average monthly enrollment in 2020 was the highest ever, exceeding the 2016 peak by 5.2%. 

That's notwithstanding the fact that initial "plan selections" as of the end of Open Enrollment for 2016 exceeded the 2020 end-of-OE tally by almost 1.2 million (12,681,874 vs. 11,444,141). Here are the official average monthly enrollment tallies by year:

Average monthly enrollment: ACA marketplace, 2016-2020

2016     10,007,113
2017       9,763,076
2018       9,895,197
2019       9,810,613
2020     10,531,978

Although end-of-OE plan selections were 9.8% higher in 2016 than in 2020, average monthly enrollment was 5.2% higher in 2020 than in 2016 (and 7.4% higher than in 2019).  Why? 

Emergency SEP enrollment, shrinking attrition boost ACA marketplace enrollment beyond yearly top lines

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In a report issued last September, Covered California, the golden state's ACA exchange, announced that effectuated enrollment in private health plans through the exchange had reached an all-time high of 1.53 million (1,527,730) as of June 2020.   That was in the midst of an emergency Special Enrollment Period (SEP), effectively a second open enrollment season, implemented by California in response to the Covid-19 pandemic.  (In normal years, SEPs are open only to individuals who can demonstrate a qualifying "life change," such as loss of job-based insurance.)

The emergency SEP ran from March 20 through August 31, 2020. According to the September report, SEP enrollment increased by more than 100% over the same period in 2019, to 289,460.  As the CoveredCA report stresses, that's in contrast to a mere 27% increase in SEP enrollment in the 38 states then using the federal exchange, HealthCare.gov, for which the Trump administration refused to open an emergency SEP.  In September, active membership enrolled through CoveredCA reached a new all-time high, 1,551,470.  

Driven largely by the boost in SEP enrollment, plan selections as of the end of OE 2021 in California finally surpassed their 2016 high point of 1,575,340, reaching 1,625,546. (The term "plan selections" acknowledges that not all those who "enroll" in plans during OE make a first payment and thus "effectuate" enrollment and become, in CoveredCA parlance, "active members").  

While plan selections as of the end of OE have always served as the headline number for ACA marketplace enrollment, they provide a somewhat misleading picture. Every year, an average of about 10% of those who "enroll" in plans during OE never pay their first premiums, and attrition continues throughout the year, as disenrollments exceed SEP enrollments -- at least through 2019, the last year for which monthly enrollment has been published.  But attrition has been shrinking beginning in 2018, perhaps because the silver loading that began that year sharply reduced net-of-subsidy premiums for many enrollees, including a substantial number who paid zero premium.  In 2016, national enrollment as of December was 28% below the end-of-OE total for plan selections. In 2019, December enrollment was just 20% below the end-of-OE tally.

In response to the pandemic, ACA marketplace enrollment was likely up 6 percent-plus by June 2020, year-over-year

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See June 2021 update below the first chart.

CMS has released average monthly effectuated enrollment in the ACA marketplace for the first half of 2020. Combined with updated data about enrollment from February through May 2020 via the Special Enrollment Periods (SEPs) granted to people who lose access to other insurance or undergo other "life changes" outside the annual Open Enrollment period, the new data offers some measure of the extent to which Americans turned to the marketplace in response to loss of employer coverage triggered by the pandemic.

While total enrollments as of the end of Open Enrollment* were nearly identical in 2019 and 2020 (total plan selections down by 0.03%), average monthly enrollment through June (10,543,098) was up 3.4% in 2020 compared to June 2019 (10,194,206).

The average monthly enrollment comparison probably understates the impact of increased enrollment via SEP and improved retention during the pandemic months. The averages include monthly totals for January through March, when the pandemic's effects were zero to minimal. In June 2019,** effectuated enrollment was 9,797,989, 7.4% below the total for February 2019. We don't yet have a comparable figure for June 2020: it will be included in the effectuated enrollment snapshot for February 2021, which probably won't drop until this summer. But the year-over-year increase as of June 2020 was almost certainly well above the 3.4% half-year increase in average enrollment, and the increase likely continued to grow throughout 2020.

The retentive ACA marketplace, revisited

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In my last post, I noted that enrollment drops in the ACA marketplace recorded in each year of the Trump era at the end of Open Enrollment more or less evaporate in yearly comparisons of average monthly enrollment, or end-of-year enrollment.

That is, it seems that fewer people in the last two years drop out without paying, and perhaps a higher percentage remain enrolled all year (many people in the ACA marketplace do have good reasons not to remain enrolled all year -- one of the marketplace's vital roles is as a stopgap). That's congruent with another change recorded in 2019: new enrollments down (-15.7%), re-enrollments up (2.3%), as of the end of Open Enrollment.

Why have apparent enrollment drops as of the end of OE in each of the last three years either shrunk or eroded entirely over the course of the year? A few possibilities:

CMS subtext: The ACA marketplace is in recovery

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The CMS report on long-term enrollment trends in the ACA marketplace has a stark lede:

During two successive years of declining enrollment, from 2016 to 2018, unsubsidized enrollment declined by 2.5 million people, representing a 40 percent drop nationally. 

That's bad. But the report includes data that leads to a clear conclusion: The ACA-compliant individual market has stabilized. It is rife with problems and there are many enrollees whom it does not serve well, but it's passed through a crisis. Consider the following points (some derived from the report, others not):

1. Subsidized enrollment was higher in 2018 than in 2016, generally understood to be the enrollment peak. In fact, total on-exchange enrollment was higher in December 2018 than in 2016. (Off-exchange enrollment, where the bulk of unsubsidized enrollment occurs, did drop sharply in those years.)


2. Subsidized enrollment is higher in 2019 than in 2018, as of February of each year, when all enrollees have had at least one payment due (see CMS's  (2018 and 2019 Effectuated Enrollment Snapshots). 

Is subsidized enrollment in the ACA marketplace really up since 2016?

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CMS's report on long-term enrollment trends in the ACA marketplace released this week emphasized the 40% drop in unsubsidized enrollment from 2016 to 2018. But the counterpoint came as something of a surprise: subsidized enrollment, according to CMS, is up since 2016.

If you look at the most often cited enrollment numbers for each year -- total plan selections reported by CMS annually at the end of the open enrollment season  -- total subsidized enrollment is down substantially -- 7.1% from 2016 to 2018, and 7.7% from 2016 to 2019. But average monthly enrollment was higher in 2018 than in 2016 -- and probably will be slightly higher this year.

It might appear that retention has improved -- more people stay in their plans for more of the year. But that's not clear, as average monthly enrollment in 2018 is not quite the same measure as in years prior.  Let's look at the numbers: