ACA marketplace enrollment growth in 2025 reflects year-round enrollment

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Renewals tend to increase over the years (until they don't)

Writing about the ACA marketplace at this point has an elegiac feel (as does writing about almost any not-depraved or degraded aspect of American life). As of 2026, coverage is likely to be far less affordable, out of pocket costs will rise as more enrollees fall back on bronze plans, and enrollment is likely to drop precipitously. And that’s a near-best-case scenario, barring repeal or some kind of not fully imaginable regulatory assault (or judicial assault, e.g., on free preventive care).

That said, I’ve been mulling this year’s new peak in enrollment, driven primarily by a large number of renewals. That’s fueled not only by the 31% year-over-year enrollment surge in OEP 2024 but by continuous off-season enrollment for applicants with income under 150% FPL (in place since early 2022) and by off-season enrollment from those disenrolled from Medicaid during the unwinding, which was essentially done by last summer. (New enrollment dropped from 5.2 million in OEP 2024 to 3.9 million in OEP 2025.)

All that said, I wanted to look at year-round enrollment patterns through the Trump and Biden eras. I no longer refer to the January-to-December enrollment fluctuations as a question of “retention,” as there has been so much off-season enrollment since 2022; a slight drop or even increase from January to December does not give a clear picture of how long people are remaining enrolled. On the other hand, one perhaps-obvious fact that jumps out from the table below is that in all years, almost everyone who is enrolled as of December renews, actively or passively. And in the Biden years, thanks mainly to the ARPA subsidy boosts, fall-off from the end of OEP to “early effectuated enrollment in February is minimal - -that is, the auto-re-enrolled do not drop coverage in droves when the first premium payment (often $0, thanks to ARPA) is due (retention also improved through the Trump years, as cuts to outreach and marketing and a shortened OEP apparently culled more marginal enrollees).

ACA marketplace enrollment in nonexpansion states is up 73% since 2020

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CMS dropped its next-to-last snapshot of ACA marketplace enrollment for 2023 today. Enrollment remains on pace for a 13% year-over-year increase.

Charles Gaba has year-over-year breakouts for each state as well as for HealthCare.gov states, state-based exchanges (SBEs), and states that have refused to enact the ACA Medicaid expansion (or, in the case of South Dakota, not yet enacted an expansion that will kick off this summer). Salient facts among those breakouts:

• Enrollment in the 18 SBEs is down slightly (2.8%).

• Enrollment in all states that have enacted the ACA Medicaid expansion is up 2.6%

• Enrollment in 12 nonexpansion states is up 23.4%.

• Enrollment in Texas is up 32% — probably triggered in part by a state law effectively requiring insurers to price gold plans lower than silver plans.

I don’t think we’ve fully fathomed the enrollment growth in nonexpansion states during the pandemic years. Since the end of the Open Enrollment Period for 2020, which ended December 15, 2019 in HealthCare.gov states (e.g., in all nonexpansion states), enrollment in the twelve states that have not enacted the expansion to date has increased by 73%. By the end of Open Enrollment on January 15, the increase will probably top 75%. Florida and Texas alone have added more than 2.4 million enrollees in those three years. The twelve states together have added 3.6 million enrollees and account for 55% of enrollment nationally.

ACA marketplace enrollment up 45% in two years in nonexpansion states

The final snapshot for the Open Enrollment Period on HealthCare.gov and ten state-based exchanges is in. We're almost done, though eight SBEs are still open. Already, enrollment in marketplace plans is up 21% over OEP 2021, to a record-breaking 14.5 million nationally, well above the previous high of 12.7 million in 2016.

Two caveats. First, when the Trump administration cut OEP in HealthCare.gov to six weeks (Nov. 1 - Dec. 15) and gutted advertising and enrollment assistance in HealthCare.gov states, while plan selection in OEP dropped, attrition also dropped -- that is, the percentage of people who never paid their first premium went way down. Early effectuated enrollment went from 85% of OEP plan selections in 2016 to 94% in  2021. A longer OEP and heavier outreach apparently attracts more marginal enrollees -- though with benchmark silver plans now free up at incomes up to 150% FPL and cheaper at all incomes, attrition may not drop to pre-2017 levels. 

Second, the steep premium hikes of 2017 and 2018 decimated off-exchange enrollment in ACA-compliant plans, which dropped from 5.0 million in Q1 2016 to 2.1 million in Q1 2019, by KFF's estimate. All told, individual individual market enrollment may be about where it was at the 2016 peak.

At healthinsurance.org: Closeup of the ACA enrollment surge of 2021-2022

At healthinsurance.org, I have a post up this morning reviewing the surge in ACA marketplace enrollment  triggered by the pandemic and further spurred by the major boost to premium subsidies provided through 2022 in  the American Rescue Plan Act enacted last March.  

Long story short: from mid-December 2019 to mid-December 2021, plan selections during the annual Open Enrollment Period increased by 29% in the 33 states currently using HealthCare.gov, and most likely by about 25% for all states (final enrollment figures for the OEP are usually released in March). 

• Two thirds of the enrollment gains are in states that have refused to enact the ACA Medicaid expansion.
• Some new enrollees in those states may have climbed over the 100% FPL minimum income threshold for ACA subsidy eligibility. 
• Many new enrollees are getting free silver plans with strong Cost Sharing Reduction 
• Enrollment increases in the current OEP build on and extend the gains during the emergency Special Enrollment Period that ran from Feb. 15 through August 15 in HealthCare.gov states.
• The strong enrollment gains should compel Democrats to extend the ARPA subsidy boosts, which expire after this year.

I hope you'll give it a read.

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ACA signup: it ain't over when it's over

[Update, 3/26: Yesterday's announcement that a "special enrollment period" will be granted to anyone who claims s/he tried to enroll before 3/31 underscores the year-round fluidity of enrollment outlined below.]

Anyone who's paying attention knows that March 31 is the open enrollment deadline. After that date, you can't "get covered" for 2014.

Unless, that is, you qualify for Medicaid -- or experience a "qualifying life event" such as a job loss or divorce or childbirth. That's a lot of people.

Roll on, Medicaid, roll on

Medicaid enrollment is continuous. State agencies and private-sector partners work year-round to get kids enrolled in CHIP.  Adults newly eligible in states that have enacted the ACA's Medicaid expansion can enroll year-round too. Enrollment won't be possible through Healthcare.gov, but individuals can apply through conventional channels, and nonprofits working to enroll the uninsured will continue their outreach after 3/31.