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.)

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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A sticky ACA marketplace: Effectuated enrollment (early 2024) and Average Monthly Enrollment (2023)

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zero premium is quite the adhesive

Early this month CMS released its annual report showing “early effectuated enrollment” in the ACA marketplace — that is, enrollment by state as of February, the first month after Open Enrollment ends for the current year (2024) in the federal marketplace, HealthCare.gov. The report also shows Average Monthly Enrollment and month-by-month enrollment for 2023.

In era where, thanks to the subsidy enhancements enacted in the American Rescue Plan Act in March 2021, almost half of all enrollees are eligible for free benchmark silver coverage, the percentage of those who select plans during OEP but never effectuate coverage (e.g., by paying a premium, if one is due) continues to drop. Of those who selected plans during the Open Enrollment Period for 2024, 97% had effectuated coverage as of February.

And in an era where, as of early 2022, prospective enrollees who report income below 150% of the Federal Poverty Level (46% of enrollees in OEP 2024) can enroll year-round, Average Monthly Enrollment as a percentage of initial enrollment during OEP continues to rise. In 2016 — the year of peak OEP enrollment before the ARPA subsidies kicked in for OEP 2022 — enrollment in December was 84.2% of enrollment as of March, the first month after OEP ended that year. In 2020, the last year before mass enrollment was enabled after OEP (thanks to a pandemic emergency Special Enrollment Period in 2021), December enrollment was 94.3% of enrollment in February the first month after OEP. In 2023, December enrollment was 113.5% of enrollment in February.

The upshot: enrollment growth in the post-ARPA era is far higher when measured in terms of Average Monthly Enrollment or Early Effectuated Enrollment as opposed to OEP plan selections. The two tables below illustrate. I’ve emphasized enrollment growth since 2016, the peak year for OEP on-exchange enrollment until 2022.

Sources: Marketplace Open Enrollment Public Use Files and Full-Year and February Effectuated Enrollment tables*, available via the 2024 Early Effectuated Enrollment Snapshot (links at FN 2).

Total marketplace enrollment likely approaches 13 million

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Axios reports that Vice President Harris will announce today that more than 2.5 million people have signed up for marketplace coverage during the emergency Special Enrollment Period that began on February 15 and ends on August 15. (Yesterday, Charles Gaba estimated 2.57 million total SEP enrollments as of July 31.) [Update: CMS's SEP report through July 31 is out and cites the 2.5 million total.]

Just for fun, let's take a stab on where total marketplace enrollment likely stands right now. 

We know that effectuated enrollment totaled 11,290,546 in February, and that about 2.5 million additional enrollees have been logged since then. The wild card is disenrollments during those months. To estimate them, our best hints come from monthly enrollment tallies in 2020, recorded in the effectuated enrollment snapshot for February 2021.

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

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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.

Attrition was reduced throughout the Trump years; possible causes are discussed here. (In brief, the Trump administration made it harder to enroll, weeding out less motivated enrollees, while silver loading made coverage much cheaper for a significant number of enrollees.) Last spring, as the pandemic triggered tens of millions of layoffs, 12 state exchanges opened emergency Special Enrollment Periods (SEPs) in which anyone who needed insurance could enroll with relatively little friction (varying somewhat by exchange).  The Trump administration declined to open an emergency SEP for the 36 states using HealthCare.gov, but did reduce red tape for those who sought individual SEPs due to a qualifying "life change," usually loss of employer insurance. 

The net result was a steady reduction in attrition from 2017-2019 and a sharp reduction last year. In 2016, the year of peak plan selections as of the end of OE, average monthly enrollment (AME) was 79% of end-of-OE "plan selections." In 2019, AME was 86% of initial plan selections. In 2020, AME reached 92% of the end-of-OE tally.

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.

Estimate: Between 42 million and 50 million people have enrolled in ACA-compliant plans since 2014

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While only about 5% of the nonelderly U.S. population is insured through the ACA-compliant individual market for health insurance, a far larger percentage of us are likely to access the market at some point in our lives (if it survives). At healthinsurance.org, I've estimated that between 42 million and 50 million people have accessed the ACA marketplace since its launch in January 1, 2014.

I've referred readers of that post here for more explanation of the basis of that estimate. CMS does not provide a simple count, yearly or cumulatively, of unique enrollees at all times and venues: during the annual Open Enrollment, via Special Enrollment Period year-round, and off- as well as on-exchange. So here is what I have pieced together:

1. New enrollment on-exchange during Open Enrollment

In its reports and Public Use Files tallying annual marketplace enrollment, CMS breaks out the number of new enrollees (as opposed to renewals). Each year, after reporting on total signups during the Open Enrollment period, CMS later reports on effectuated enrollment  -- that is, the number of enrollees who have paid their premiums. Effectuated enrollment at its peak each year has averaged about 89% of initial signups.  In the right column below, I have estimated effectuated new enrollment in each year and in total.

Total New ACA marketplace enrollment, 2014-2020

    Source: CMS Public Use Files (see note at bottom for adjustments)

From 2014 through this year, approximately 27.7 million people have purchased plans during the annual Open Enrollment period and paid their first premiums, effectuating coverage ("approximate" because I'm applying the overall effectuated percentage to the new enrollees specifically).  Some "new" enrollees may have dropped out and returned.

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:

A CMS misinformation byte is getting into the woodwork

Axios today reports on the Kaiser Family Foundation's latest data note on individual market enrollment. The main takeaway is that unsubsidized enrollment is down by two million in 2018: brutal premium hikes are driving the unsubsidized out of the individual market.  I was brought up short, however, by this offsetting claim:

Subsidized enrollment grew by about 500,000 people.

Kaiser here is retailing CMS's comparison of effectuated enrollment as of March 2017 and March 2018, tallying those who enrolled on-exchange paid their premiums in February.  These snapshots show total on-exchange enrollment at 10.6 million in March 2018 and 10.3 million in March 2017, and subsidized enrollment at 9.2 million in 2018 vs. 8.7 million in 2017.

As I noted three weeks ago, that comparison is erroneous:

No, CMS, ACA marketplace enrollment isn't up this year, and doesn't justify navigator funding cuts

To justify gutting funding for the navigators who help low income people enroll in health insurance subsidized by the ACA (Medicaid as well as marketplace), CMS is turning a bogus talking point it concocted last year inside out. Here's the current claim, as reported by KHN's Phil Galewitz:

CMS also notes that after last year’s navigator funding was reduced, the overall enrollment in Obamacare plans increased slightly (when counting people who paid their first month’s premiums) to 10.6 million people.

Comparing 2017 and 2018 totals at the end of open enrollment  (before many enrollees have paid their first premium), total ACA marketplace enrollment was down 4% this year. CMS's comparison above uses the totals from the "effectuated enrollment snapshots" from 2017 and 2018, which tracked how many people were enrolled (and had paid their first premiums) as of February in each year. The reported total at that point was 10.3 million in 2017, vs. 10.6 million this year.

As Charles Gaba pointed out last year (and revisits here), however, the 2017 "snapshot" exaggerated early attrition by failing to take into account the fact that those who enrolled between 1/15 and 1/31 (the final day of OE in 2017) did not have payments due until March 1.  There were 539,352* enrollees in that time frame.  None of them could effectuated their coverage for February, which is the population counted in the "snapshot." If those enrollees effectuated coverage at the same rate as enrollees before 1/15 (88.5%), there were 10.8 million who had effectuated or would soon effectuate as of the time of CMS's tally. That total outstrips this year's by 2% .**

Unsubsidized ACA marketplace enrollees drop out early

Early this week, CMS reported that unsubsidized enrollment in ACA-compliant plans dropped 20% in 2018, while subsidized enrollment dropped just 3%. I pointed out that on-exchange unsubsidized enrollment dropped much more modestly, just 6%. That bespeaks a still steeper drop in off-exchange enrollment, suggesting that some previous off-exchange enrollees may have moved on-exchange in 2018 -- some obtaining subsidies, others not.

Today Charles Gaba notes that while unsubsidized on-exchange enrollment did not drop precipitously this year, first-month attrition among the unsubsidized who enrolled on-exchange was massive -- in a year in which overall attrition appears lighter than usual (over 80% of on-exchange enrollees are subsidized). While only 5.6% of subsidized enrollees are reported to have dropped coverage as March 15, 29%* of unsubsidized enrollees did.  This may not be surprising in a year in which premiums rose an average of 27%, largely as a result of Republican sabotage (cutoff of direct CSR reimbursement, radical cuts in enrollment assistance and advertising, weak enforcement of the individual mandate).

While the attrition among the unsubsidized this year is startling, it continues a pattern. Far higher percentages of unsubsidized than subsidized enrollees also dropped out in 2017 and 2016, rising each year. At the same time, attrition among subsidized enrollees dropped each year.

He who buys bronze absconds

In the spring of 2014 my son, knowing he'd enter a graduate program that September, switched his health insurance from COBRA to a bronze marketplace plan. Healthy, he gambled the premium difference between bronze and silver (or bronze and COBRA) against the deductible difference, essentially settling for catastrophic protection for a limited period.

Yesterday I noted that attrition in the ACA marketplace, which is sharpest in the months immediately following open enrollment since 10 percent or more of those who select plans never pay the first premium, is highest among those who enroll in bronze plans.   As of March 31 of this year, while bronze enrollment dropped 15.5%, from 2,873,422 to 2,427,337, silver dropped just 9.3%, from 8,520,787 to 7,721,983. A similar discrepancy was recorded in the spring of 2015.

It turns out that the same pattern held throughout the year in 2015. By December 31, total enrollment was down from 11,688,074 as of  Feb. 22, 2015 (not all of it "effectuated," or paid for in the first month) to 8,780,545, a 24.8% drop. Among bronze plan holders, the drop was 30.5%, versus 23.2% for silver, 18.8% for gold and 18.6% for platinum. Those with gold, hold -- relatively speaking.  And he who buys bronze... absconds.

As bronze plans typically carry deductibles over $6,000, many enrollees may decide that they're not worth the money. But I think it's also likely that those who know they have a short-term need for insurance, like my son, may lean toward bronze, basically holding their breath until employer insurance, or school-based insurance, or a spouse's insurance kicks in.

ACA Marketplace snapshot: Bronze plan enrollees drop plans at higher rate than silver plan holders

CMS just released its "attrition report" for the ACA marketplace -- that is, its first snapshot of "effectuated enrollment" as of March 31 after tallying total plan selections at the end of open enrollment on Feb. 1.

The drop is comparable to last year's as of March 31: enrollment is down from 12.7 million to 11.1 million. That is, it's down 13%. As CMS points out, enrollments took place earlier on average this year, so enrollees had somewhat longer to drop out by 3/31.

As I always keep an eye on takeup of Cost Sharing Reduction (CSR) subsidies, available only with silver plans, I was interested to note that as the smoke cleared, the overall rate of silver plan enrollment for the whole marketplace rose markedly, from 67.1% on Feb. 1 to 69.7% as of March 31. The percentage of enrollees in bronze plans went down, from 22.6% to 21.9%.

While bronze enrollment dropped 15.5%, from 2,873,422 to 2,427,337. Silver dropped just 9.3%, from 8,520,787 to 7,721,983.  It makes sense that more people would drop bronze plans, with their deductibles typically north of $6,000 per person. Similarly, by March 31 of last year, bronze enrollment had dropped 15.9% since the end of open enrollment, compared to 11.5% for silver. By June 30, 2015,  bronze was down 18.6%,, and silver 13.3%.

This year, then, silver attrition is 60% of bronze attrition, versus 70% last year. Last year, government audits of enrollees' income claims led to hundreds of thousands having their CSR (and premium) subsidies eliminated or reduced, though that drop was not reported until the enrollment snapshot for June 31, released last September. This year, better data matching has reduced such subsidy reductions by more than two thirds.  Perhaps the higher volume of data audits in 2015 induced a slightly higher proportion of silver plan enrollees to drop their plans, since a good proportion lost some or all of their CSR.

Updated 7/1.