On January 28, 2026, the Centers for Medicaid & Medicare Services (CMS) released its second national snapshot of 2026 Affordable Care Act (ACA) Marketplace Open Enrollment (OE) activity. While this update is not a final accounting of enrollment activity, it is likely to be the last OE federal data release for some time and offers an early look at how enrollment trends are shifting in the wake of expired enhanced premium tax credits and new eligibility standards under the 2025 budget reconciliation act (P.L. 119-21, OBBBA). 

In this article, Health Management Associates (HMA) and Wakely, an HMA company, highlight findings from their analysis of the 2026 OE activity and compare this activity with 2025 data. This analysis builds on the findings in their January 2026 analysis (here) and will provide important context for the 2027 plan year. 

Overall Enrollment Trends 

CMS reports that 2026 plan selections decreased by 5 percent from 2025, with enrollment declining across both new and returning consumers. New sign-ups dropped by 14 percent and renewals fell by 3 percent (Table 1). State-based Marketplace (SBM) enrollment dipped modestly, though many SBMs were still enrolling consumers in late January. 

Table 1. Comparison of 2026 and 2025 Open Enrollment 

	2026	2025	Net Change
Total	22,973,219	24,166,491	(1,193,272)
New Consumers	3,382,189	3,938,907	(556,718)
Returning Consumers	19,591,030	20,227,584	(636,554)

 

Variation Across State-Based and Federally Facilitated Marketplaces 

Enrollment patterns varied substantially across states. 

SBMs: 

• New Mexico saw the largest year-over-year increase (14%), attributed to state-funded subsidies designed to offset the loss of enhanced premium tax credits (ePTCs). 
• Georgia experienced a 14 percent decline, the steepest drop among SBMs. 

Federally Facilitated Marketplace (FFM) States: 

• Overall, FFM enrollment fell 5 percent. 
• Texas led FFM states with a 5 percent increase in plan selections. 
• Ohio and North Carolina experienced substantial enrollment declines, 20 percent and 22 percent respectively. 

What This Tells Us—and What It Doesn’t Tell Us Yet 

FFM data are as of January 15, 2026, and measure plan selections after the OE period ended. Within the FFM, state-by-state enrollment activity varied significantly. Some of this variation is surprising and not readily explainable from the available data and will be a focus of future HMA and Wakely analyses. 

The data include neither effectuated enrollment nor paid enrollment—data which will be key to fully understanding 2026 enrollment trends and the impact of changing federal policies, including the ePTC expiration and changing eligibility standards introduced in 2026 as the result of OBBBA. 

Early SBM data suggest significantly higher cancellation and disenrollment rates than in previous years. 

SBMs are sharing that they expect substantial affordability-driven voluntary and nonpayment terminations over the first half of 2026. 

Monitoring paid enrollments, attrition, and grace period dynamics, including retro-terminations, will be key to understanding market dynamics and 2027 pricing. 

Connect with Us 

HMA and Wakley experts have considerable experience working with states, insurers, and federal policymakers with jurisdiction over the Marketplace. We work with these entities to inform, analyze, and shape federal policies and conduct impact analyses on pricing, enrollment, administration, and operations. HMA also provides strategic and project management support for the implementation of finalized policies. 

Please contact Michael Cohen, Taylor Gehrke, or Zachary Sherman with questions, follow-up, or if you would like expert assistance exploring any of the issues discussed in this post.

On February 3, 2026, Congress finalized federal funding for fiscal year (FY) 2026, with the House passing the Consolidated Appropriations Act (CAA), 2026, with a vote of 217-214, following Senate approval last week. The president signed the CAA (H.R. 7148) shortly thereafter. The law provides full-year appropriations for the Departments of Health and Human Services (HHS), Housing and Urban Development, Labor, and several other departments. 

This year’s HHS funding bill is notable not only for what it includes, but also for what it omits. It restores or maintains funding for key public health and research agencies previously proposed for elimination in the president’s FY 2026 budget request, extends several healthcare programs, and contains a significant package of pharmacy benefit manager (PBM) reforms. All of this activity comes as the Administration announces new grant programs and policy efforts related to its signature priorities. 

In this article, we review the major funding and policies approved in the HHS spending bill. We also address key considerations for healthcare organizations as they anticipate downstream funding and policy developments and develop advocacy initiatives for federal FY 2027 bills. 

HHS Funding Levels and Direction 

The bill provides $116.8 billion for HHS, an increase of $210 million over FY 2025, and rejects large-scale structural reorganizations proposed in the president’s FY 2026 budget. This provision preserves funding for the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), Health Resources & Services Administration (HRSA), and the Substance Abuse and Mental Health Services Administration (SAMHSA) 

Table 1. HHS Agency Funding Highlights, FY 2026 

Agency	FY 2026 Funding	(+/-) Compared with FY 2025
Administration for Strategic Preparedness and Response (ASPR)	$3.7 billion	+$58 million
CDC	$9.2 billion	level funding
Centers for Medicare & Medicaid Services (CMS), administrative expenses only	$3.7 billion	level funding
HRSA	$8.9 billion	+$415 million
National Institutes of Health (NIH)	$48.7 billion	+$929 million
SAMHSA	$7.4 billion	+$65 million

 

The bill also extends mandatory funding for community health centers, special diabetes programs, the National Health Service Corps, and Teaching Health Center Graduate Medical Education. 

PBM Reforms in the Package 

In one closely watched area of federal policymaking, the FY 2026 package includes a substantial set of PBM-related reforms that largely mirror the bipartisan package negotiated but not enacted in December 2024. These reforms have implications across Medicare Part D, commercial insurance, and employer-sponsored plans. 

The legislation contains the following PBM reforms: 

• Prohibits PBMs from deriving remuneration linked to drug prices for Medicare-covered Part D drugs 
• Restricts spread pricing in Medicaid, eliminating a major driver of PBM revenue 
• Requires contractual transparency, mandating that PBMs clearly define pricing terms in agreements with Part D plan sponsors 
• Adds new PBM reporting obligations, including drug price reporting and rebate disclosures 
• Requires 100 percent passthrough of rebates in ERISA-regulated plans for new, renewed, or extended contracts beginning 30 months after enactment 
• Expands audit rights for plan sponsors 
• Codifies the “any willing pharmacy” requirement for Medicare plan sponsors 

These provisions position 2026 as a consequential year for PBM regulation, increasing transparency, strengthening plan leverage, and heightening HHS oversight. 

Healthcare Extenders and Program Reauthorizations 

The bill includes a broad set of Medicaid, Medicare, and public health program extenders, affecting providers, patients, states, and managed care plans. 

Medicaid 

• Postpones reductions in the Disproportionate Share Hospital (DSH) allotments until FY 2028 
• Changes the DSH cap calculation to broaden which patient costs count toward Medicaid shortfall 
• Requires states to develop and implement a process to allow certain out-of-state pediatric providers to deliver services without additional screening for three years 
• Removes age limits on Medicaid’s Ticket to Work program, allowing adults older than age 65 to participate and requires state compliance by January 1, 2028 
• Establishes new maternity care reporting requirements for rural hospitals, with dedicated federal funding for hospitals and states to comply with the reporting 

Medicare 

Congress extends several key programs and payment provisions, including: 

• Telehealth flexibilities through December 31, 2027 
• Incentive payments for participation in eligible alternative payment models through payment year 2028 (for performance year 2026) and applies an adjustment amount of 3.1 percent for 2028 
• Acute Hospital Care at Home waivers through 2030 
• Low-volume and Medicare-dependent hospital payment adjustments 
• The 1.0 work geographic practice cost index floor used in the calculation of payments under the Medicare physician fee schedule through December 31, 2026 
• Add-on payments for ambulance services 
• Continuation of Part D coverage for certain antivirals and modifications to hospice payment caps 

Behavioral Health Policy 

The appropriations bill was finalized as the administration announced new funding and policy initiatives to support behavioral health, crisis services, workforce expansion, and youth mental health—efforts mirrored in SAMHSA’s increased appropriations. 

SAMHSA’s $7.4 billion budget includes: 

• $1.6 billion for State Opioid Response grants 
• $1.01 billion for the Mental Health Block Grant 
• $535 million for the 988 Suicide and Crisis Lifeline 

Considerations for Stakeholders 

Federal funding and policy developments affect state budget dynamics as many states are now releasing 2026–2027 budget proposals as well as the operational and growth plans of healthcare organizations and partners. 

A few key takeaways from the FY 2026 funding bill include: 

• Federal appropriations signal congressional and administration priorities and have downstream impact on upcoming rounds of grant cycles, including SAMSHA and HRSA awards. 
• The approved funding and certain policy extensions provide operational stability and reduce near-term fiscal pressure, such as the further delay of Medicaid DSH cuts. The extra time will allow healthcare entities to prepare for future reductions and plan for financial sustainability. 
• Agency and program funding emphasize oversight, program integrity, and compliance. In addition, fraud and program integrity priorities are woven into certain new policies and program extensions, including PBM reforms, flexibility for pediatric care across state borders, and rural maternity cost reporting requirements, among others. 

Connect with Us 

If you would like deeper analysis or state and stakeholder-specific effects, HMA’s policy experts are available to assist.