The upcoming 2026 open enrollment period for the Affordable Care Act (ACA) marketplaces is likely to be one of the most complex since the program’s implementation. Recent federal policy changes, ongoing litigation, and uncertainty around the extension of enhanced premium tax credits (ePTCs) are converging to create significant challenges for federal and state regulators, policymakers, and issuers. Rising premiums, expiring subsidies, and shifting federal regulations also have created an environment of significant uncertainty for consumers, navigators, and brokers.
A new report, Complexity for the 2026 Marketplace Open Enrollment: Risks of Consumer Confusion & Coverage Loss, authored by Health Management Associates (HMA) and Wakely, an HMA Company, with support from the Robert Wood Johnson Foundation, explains these changes and their collective effect on costs and consumer experiences.
In this article, HMA and Wakely experts preview the options policymakers, states, regulators, issuers, consumer advocates, enrollment assisters, and other stakeholders can implement to mitigate potential confusion and coverage losses.
Federal Policy Shifts Driving Complexity
Central to the current challenges is the scheduled expiration of ePTCs at the end of 2025. Without congressional action, the “subsidy cliff” returns, eliminating subsidies for consumers with incomes above 400 percent of the federal poverty level and reducing assistance for those living below. Early filings suggest average premium increases of 20 percent, which could be untenable for millions of families and small business owners enrolling in individual market coverage.
Additional federal changes compound the challenge:
- The 2025 Budget Reconciliation Act (OBBBA) removes advance premium tax credit (APTC) eligibility for certain lawfully present immigrant populations and eliminates Internal Revenue Service repayment caps on excess APTCs, including financial risk for consumers.
- The Marketplace Program Integrity and Affordability (MIA) Rule changed eligibility and enrollment requirements. Some provisions are paused due to ongoing litigation (City of Columbus v. Kennedy and State of California v. Kennedy), creating implementation uncertainty.
- CMS updated issuer renewal and discontinuation notice guidance, allowing issuers to omit premium and APTC information from their 2026 renewal notices, reducing clarity for consumers comparing plans.
- Changes to catastrophic plan policy broadens eligibility but may create confusion when comparing options.
These changes are occurring alongside notable issuer exits, affecting millions of enrollees. States and issuers must be prepared to manage plan mapping and consumer transitions, potentially involving different networks and benefits.
Emergent Conditions for Open Enrollment Season
The combined impact of these changes is likely to increase marketplace call center traffic, broker and navigator assistance requests, eligibility appeals, and special enrollment activity, all of which will strain system capacity. Vulnerable populations, including those with limited English proficiency and those living in non-expansion states, face heightened risks of disenrollment. Operational strain is expected across marketplaces, issuers, and enrollment assistance networks.
Enrollment losses and affordability challenges also will be more significant in states that have not expanded Medicaid, particularly for lower income and older enrollees. The ACA Marketplaces experienced an influx of new enrollees as a result of ePTC, leading to historical enrollment growth in these states. On average, non-expansion states have seen their ACA Marketplaces grow by 152 percent from 2020 to 2024 versus 47 percent average growth in expansion states.
Regulators and issuers also must navigate the legal uncertainty surrounding the 2025 Marketplace Integrity and Affordability Rule and OBBBA provisions. With litigation ongoing, some rules may change mid-enrollment, requiring flexible implementation and communication strategies.
Strategies to Navigate the Current Complexity
To address these challenges, stakeholders can take several steps, including:
- Clear, Consistent Messaging. Consumers will need clear communications advising them to review and update their plan selections. Communications should be direct, succinct, culturally appropriate, multilingual, and delivered repeatedly and through multiple channels.
- Strengthened Noticing. It will be critical that federal, state, and issuer notifications to consumers be aligned, when possible. Notices should clearly explain premium and eligibility changes for affected populations and the actions they need to take.
- Expanded Outreach. Enrollment assistance and direct to consumer education are critical, especially for low-income consumers, immigrants, and those previously auto enrolled. Partnerships with brokers, assisters, and community organizations will be key to reaching difficult-to-engage populations.
- Enhanced Capacity. Investments in call center staffing, assister funding, and broker training can help address increased volume of consumer inquiries. Marketplace and issuer call centers should leverage available data to enhance their ability to serve affected consumers. States may consider adjusting compensation models to reflect the increased complexity.
- Policy Flexibility. Federal and state marketplaces should prepare to use operational flexibility to mitigate coverage losses. If ePTCs are extended during or after open enrollment, special enrollment periods or extended deadlines may be needed. Retroactive coverage and grace period extensions could also address gaps.
Looking Ahead
The 2026 open enrollment period will test the resilience of the ACA infrastructure. For regulators, states, and issuers, the priority must be clarity, retention, and stability. Monitoring enrollment trends, premium differentials, and consumer confusion will be essential for adapting strategies and maintaining market viability.
Without coordinated communication and outreach, coverage losses and poor plan choices could undermine individual financial protection and destabilize the broader individual market. Lessons from previous enrollment periods and Medicaid’s COVID-19 public health emergency unwinding can guide efforts to keep consumers informed and enrolled.
Connect with Us
HMA and Wakely experts are closely tracking federal policy activity and state actions to address these challenges. Our experts support states, managed care organizations, 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 optimize markets as they continue to evolve in the coming months and years. If you have questions or want to discuss the recommendations included in the report, contact our experts below.
