On April 15, 2026, Wakely Consulting Group, an HMA company, published “Who Paid, and Who Stayed? Early 2026 Enrollment Trends in the Individual Market,” the first comprehensive nationwide look at 2026 enrollment trends in the Affordable Care Act (ACA) market. While the Centers for Medicare & Medicaid Services (CMS) has released 2026 plan selection data, the Wakely report addresses who retained coverage and who did not, what we still don’t know, and what we should be watching for throughout the rest of the 2026 plan year.
This article highlights key findings in the report, related state-level data, impacts and takeaways, and actions states and other interest-holders should consider as they look to mitigate further coverage losses and address market stability in& plan year 2027 and beyond.
Key Findings from the ACA Marketplace Early Enrollment Trends Report
The Who Paid, and Who Stayed report is based on analysis of data from the Wakely National Risk Adjustment Reporting (WNRAR) project, which includes summary data from participating ACA-compliant individual market plans. WNRAR includes data from over 75 issuers representing nearly 80 percent of enrollment the individual market. Key national findings in the report include:
- Only 86% of enrollees paid their January 2026 premium.
- State variation is significant, ranging from as low as 63% paid in January to as high as 99%.
- The overall average enrollment decrease is estimated to be between 17% and 26% lower than 2025, with morbidity projected to worsen by 2.9–6.5%.
The report highlights shifts in plan choice activity driven by affordability pressures, which resulted in considerable migration away from richer benefit plans to plans with lower premiums and higher out-of-pocket maximums. Examples include:
- Silver plan enrollment fell approximately 17% from 2025.
- Bronze enrollment increased by more than 10%.
- More than 13% of 2025 Gold plan enrollees selected a lower priced, Bronze tier plan in 2026.
The report also demonstrated the importance and value of outreach, operational excellence, and state-level affordability mitigation strategies. Examples include:
- Enrollment decreases are lower in states with state-based marketplaces (SBMs) and expected to stay lower than Healthcare.gov states, largely because of proactive outreach and marketing initiatives, lower net premium increases, and state affordability programs.
- States with premium alignment and silver-loading as a policy lever for improving gold plan affordability are seeing results. Gold plan enrollment increased by 10 percentage points in states where gold plans cost less than silver plans, whereas gold enrollment did not materially change in states where silver plans cost less. For states, this provides a lever to assist consumers seeking to shift into plans with lower cost-sharing without increasing premiums.
State-Reported Early Enrollment Results
Many states warned of coverage losses as a result of changing federal policies and the expiration of enhanced premium tax credits (ePTCs). State-specific reporting for 2026 validates the findings in the Wakely report. The recently released state-level data from SBMs affirms that the drop-off in enrollment through cancellations and dis-enrollments is significant. It also illustrates that state efforts to mitigate and address affordability gaps have worked to some extent but have not been enough on their own to head off coverage losses in 2026. Examples are as follows:
- In Georgia—the only SBM without Medicaid expansion—enrollment fell 27% from an estimated 1.3 million in April 2025 to approximately 950,000 in April 2026.
- In New Jersey—a state with state-funded premium subsidies, a reinsurance program, and a mandate that residents have health insurance—enrollment has decreased by more than 11% since April 2025.
- In California—another state with premium subsidies, facilitated enrollment, and an individual mandate—effectuated enrollment decreased by 7% from February 2025 to February 2026.
- Overall, SBMs are reporting that coverage drops were 24% higher from January to March 2026 than during the same period in 2025 and that the rate of plan shifting from Silver to Bronze increased significantly, quadrupling in six states.
Downstream Impact on Healthcare Access and Uncompensated Care
While not yet apparent in the early enrollment data, the downstream impact of 1) coverage losses, 2) increased enrollment in plans with higher cost-sharing, and 3) a worsening risk pool on the health of consumers, as well as the healthcare system, will be significant. Consumers may decide to postpone or forgo necessary care, which could lead to avoidable and more costly healthcare conditions. Increases in the number of people who uninsured and underinsured will have a direct and negative economic impact on provider finances, which are already strained, and uncompensated care and demands on patient assistance programs will increase accordingly.
Looking Ahead
The individual market will continue to evolve and change in the coming years as a result of future regulatory and operational changes. A shortened Open Enrollment Period, increased Medicaid redetermination requirements, and new pre-enrollment verification requirements are notable initiatives that are expected to roll out in the coming years.
Healthcare organizations and government agencies should consider the effect of these changes, including further coverage losses and instability in the individual market driven by the administrative complexity of these changes.
In addition, there are potential federal changes such as expanded availability of catastrophic plans, the introduction of non-network plans, and additional eligibility changes, which could put further strain on ACA Marketplace operations and the individual market.
Getting ahead of these changes will be critical to mitigating coverage losses and ensuring the long-term stability and viability of the individual market. In a federal policy environment that has largely deferred acting on ACA affordability, we expect policymakers, issuers, and other interest-holders to increasingly look to governors and state legislatures for decisive action. State subsidy and reinsurance programs are established affordability mechanisms that can provide consumers with affordability relief quickly, assuming state funding is available.
These investments can pay off for consumers from an economic perspective as well. For every additional dollar spent on state subsidies or reinsurance to maintain or increase coverage, states can expect to see reductions in uncompensated care, less reliance on patient assistance programs, and decreases in the number of consumers who forgo or delay care. In addition, investments in enrollment operations and assistance, outreach, and education will be critical to ensuring consumers are aware of the changes ahead and the actions they need to take to access and stay covered.
Connect with Us
Health Management Associates, Inc. (HMA), and Wakely colleagues are closely tracking federal policy activity and state actions to address these challenges. Our experts support states, issuers, consumer groups, and other interest-holders to achieve success in the operation of and participation in the marketplaces. Our team has broad historical knowledge of the challenges and opportunities in this market and can support every step of the planning and execution processes to improve affordability and stability as it evolves in the coming months and years.
Contact our experts below with questions about the report and to discuss opportunities to address the trends and forthcoming changes in the market.
To read more about the changes ahead, see the following reports:
