As the 2026 Affordable Care Act (ACA) Marketplace open enrollment period nears its close—and with enhanced subsidies expiring, rates shifting, and consumer behavior evolving—questions about enrollment stability, affordability, and operational readiness have rapidly moved to the forefront. Andrea Maresca, Senior Principal, at Health Management Associates, caught up with Zach Sherman, Managing Director for Coverage Policy and Program Design at HMA, and Michael Cohen, PhD, who leads much of the federal policy analysis advanced by Wakely, an HMA company, to unpack what they’re seeing so far.
Q: This year’s open enrollment period has been unusually complex. At the federal level, what stands out most so far?
Michael: The headline is that new enrollment is down sharply, while returning consumers have held steadier than expected. That reflects the reality that the enhanced subsidies are gone, premiums have risen, and consumers are facing higher net costs across nearly every market.
But nuance matters: The real question now is how many of these plan selections will effectuate—meaning consumers pay their first month premium, and how many will stay enrolled the entire year? Average effectuated enrollment throughout the year is what truly determines 2026 risk mix and market stability.
Q: Enrollment appears to vary considerably from state to state. What are you hearing from state partners?
Zach: It’s a tale of two markets. StateBased Exchanges (SBEs) are generally seeing less attrition and, in some cases, even modest increases in plan selections. The reason is simple: Many states are doing a lot of heavy lifting to offset the loss of federal support.
For example, SBEs perform earlier and have more customized outreach. We’ve also seen some states step in and offer state-funded subsidies, which are cushioning the affordability loss in places like New Mexico, Maryland, and California.
While still early, the data suggest that states with heavy investment in awareness and enrollment assistance, operational support, and affordability are weathering the transition better because they have more tools to stabilize the consumer experience.
Q: There’s been a lot of speculation about how consumers are responding to the end of enhanced subsidies. What are the early signs?
Michael: Consumers appear to be buying leaner benefits or different metal tiers to manage premium increases.
Another underrecognized but incredibly important dynamic is that autoreenrolled consumers may not effectuate coverage once they see the final outofpocket premium. That dynamic won’t be fully understood until March, April, and even May.
Q: Idaho is a particularly interesting early case study. What are you learning from the first state to complete enrollment?
Zach: Your Health Idaho’s open enrollment finished on December 15, and while they saw a slight increase in plan selections, state officials are not celebrating as they expect a large wave of cancellations—up to 20,000—due to the expiring subsidies.
That’s the clearest early indication that affordability is the defining issue of 2026. States are preparing for higher-than-usual enrollment attrition in quarters one and two (Q1 and Q2), and they’re thinking hard about customer service capacity as consumers navigate changing net premiums, increased deductibles and out-of-pocket costs, and nonpayment grace periods.
Q: Are there policy levers states can still pull to mitigate affordability challenges going forward?
Zach: We’re seeing states explore options for mitigating affordability gaps and enrollment losses, including through state subsidy programs and increased investment in existing reinsurance programs. SBEs are also leaning on their core competencies—tailored and specific education campaigns and enrollment and plan comparison tools—to help their customers cut through the noise and navigate to the best option within their budget.
These aren’t perfect or quick fixes and most states don’t have the resources necessary to backstop the expiring subsidies, but state leaders increasingly view doing something as necessary to stabilize their markets.
Q: What should health plans, exchanges, and policymakers watch most closely over the next three months?
Michael: Effectuation, effectuation, effectuation. The composition of the effectuated population will define 2026 risk.
Zach: Agree. In addition, future regulatory action on affordability, eligibility and enrollment processes, and program integrity. The federal government is expected to issue its annual payment notice, the proposed 2027 Notice of Benefits and Payment Parameters, in the near future.
You can find more insights on the initial enrollment patterns to date in this Health Management Associates-Wakely paper, Individual ACA Open Enrollment Insights So Far and register for the 2027 ACA Considerations: Proposed NBPP and Other Key Changes and Trends.
