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 Lina Rashid, Zach Sherman, or Michael Cohen 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: 

• 2027 Proposed NBPP: Analyzing State and Consumer Impacts 
• Medicaid Changes in the OBBBA and Implications for the Marketplace and Individual Market in 2027 
• ACA Non-Network Plans: How Big of a Disruption? 

As the Centers for Medicare & Medicaid Services (CMS) advances through the 2027 Medicare payment rule cycle, stakeholders across Medicare Advantage (MA) and the provider community are assessing how proposed changes could affect payment, utilization, and longer-term revenue. To better understand what to watch as draft rules move toward finalization, Jen Colamonico, Vice President, Strategy and Communications at Health Management Associates (HMA), caught up with Rachel Stewart, Senior Consulting Actuary with Wakley, an HMA Company. Of particular interest was CMS’s decision to eliminate the Inpatient Only List (IPO) over a three- year period. 

Q: As CMS begins releasing draft payment rules for 2027, what stands out most to you from a budgetary perspective?
Rachel: Timing and uncertainty really stand out. These policies don’t operate in isolation. Changes to Medicare fee-for-service (FFS) payment ultimately affect Medicare Advantage benchmarks, provider contracting, and long-term revenue expectations. Because bids, budgets, and contracts are set before rules are finalized, modeling different scenarios becomes essential. 

Q: One issue that has garnered significant interest is CMS’s decision to phase out Medicare’s Inpatient Only (IPO) policy, which is a list of procedures and services that must be provided on an inpatient basis. In 2026, CMS eliminated nearly 300 services, mostly musculoskeletal services, from the IPO list. How are Medicare Advantage plans thinking about the Inpatient Only list specifically? 

Rachel: Historically, many MA plans have followed the IPO policy even though they weren’t required to do so, largely because it simplified operations and aligned with Medicare fee-for-service payment systems. Plans do have flexibility in how they contract with providers, and we see a wide range of approaches in the market. Some contracts closely mirror FFS, while others incorporate more customized arrangements or risk sharing. Because of that, the direct impact of IPO changes will vary significantly across plans and provider relationships. 

Q: Where do you see the biggest potential impact for Medicare Advantage?
Rachel: I think the bigger impact may be indirect rather than tied to individual contract changes. Medicare Advantage benchmarks are driven by underlying fee-for-service spending trends. If CMS anticipates lower overall inpatient spending as procedures move to outpatient or ambulatory surgical center settings, that expectation could show up in benchmark growth rates. Even relatively small changes in benchmark growth can affect plan revenue, rebates, and benefit flexibility. 

Q: Are you already seeing signs of that in the data?
Rachel: We do see lower inpatient trends reflected in the 2027 and 2028 US per capita cost projections. It’s still unclear what’s driving those trends—whether its assumptions related to the IPO list removal or other factors. We’ve asked CMS for more clarity. From an actuarial standpoint, understanding what’s baked into those projections is critical, because so many MA financial decisions flow from them. 

Q: How does this uncertainty affect provider planning, especially for hospitals?
Rachel: Providers are understandably concerned about potential revenue shifts if cases move out of the inpatient setting. But in Medicare Advantage, the picture is more nuanced than in fee-for-service. Many MA arrangements include risk sharing, medical loss ratio targets, and quality incentive payments. If overall costs decline, providers may share in savings through those mechanisms. So, while there may be pressure on inpatient revenue, it’s not necessarily a one directional loss. 

Q: Does that mean the overall impact may be less dramatic than it appears?
Rachel: Potentially, yes—especially for organizations already participating in value-based arrangements. A reduction in unit costs doesn’t automatically mean a reduction in total provider revenue in MA. The redistribution of dollars through shared savings and quality bonuses can offset some of that pressure. That’s why understanding contract structure is just as important as understanding the policy itself. 

Q: What about quality and patient safety as procedures move to lower cost settings?
Rachel: Quality is always central in Medicare Advantage, and plans are already managing a lot of complexity related to Star ratings and quality measurement. We haven’t yet seen specific quality safeguards tied to the IPO list changes, but I would expect more discussion in the forthcoming proposed rules. From the MA side, contracting remains a key lever. Plans still have flexibility to ensure procedures are performed in appropriate settings and to align incentives with quality outcomes. 

Q: What steps do you recommend to stakeholders to prepare for the final rule and for 2027?
Rachel: Modeling helps organizations understand the range of possible outcomes rather than betting on a single assumption. We’re looking at different utilization scenarios, site of care shifts, and benchmark growth trajectories. For providers, modeling can inform contract negotiations and capital planning. For plans, it helps assess revenue risk and benefit design flexibility. It doesn’t eliminate uncertainty, but it helps organizations make informed decisions. 

Q: If you could change one thing about how these policies are rolled out, what would it be?
Rachel: Transparency. The more clarity CMS can provide around cost projections and assumptions—especially those affecting benchmarks—the better positioned actuaries, plans, and providers will be to respond. So much of Medicare Advantage pricing relies on understanding how fee-for-service is expected to evolve. Greater transparency helps everyone plan more responsibly. 

HMA’s Medicare Practice Group Can Help 

As CMS moves closer to finalizing the 2027 payment rules, actuarial modeling will continue to be an important tool for translating policy direction into financial strategy. For MA plans and providers alike, early analysis and scenario planning can help mitigate risk and identify opportunity as Medicare’s payment landscape continues to evolve. 

For additional insights, listen to Rachel Stewart and Zach Gaumer on HMA’s Vital Viewpoints podcast. Learn more about our Medicare services and solutions.