Enrollment in the Affordable Care Act (ACA) marketplace has declined significantly in 2026 as many enrollees struggle to afford higher premiums and reduced subsidies, prompting insurers to prepare for another round of rate increases in 2027.
Following record enrollment last year, sign-ups fell by approximately 1.2 million in January 2026. Consumers then faced average premium increases of 26%, compounded by the expiration of enhanced subsidies that had been available since 2021. Early data indicates that fewer people are making their premium payments, raising concerns about further market contraction.
Enrollment and Payment Trends
Recent analyses provide varying snapshots of premium payment declines. In Georgia, premium payment rates dropped by 28% in April compared to the previous year, one of the steepest decreases among states. Nationwide, internal data from the Centers for Medicare & Medicaid Services (CMS) suggests that roughly 21% of federal marketplace enrollees failed to pay January premiums, a significant increase from prior years.
States operating their own ACA exchanges tend to have higher payment rates—around 92%—than those using the federal marketplace, where payment rates fall between 82% and 84%. This disparity is linked to states that allocated funds to supplement shrinking federal subsidies, such as New Mexico, which recorded an increase in payment compliance.
Factors Driving Enrollment Decline
Experts attribute the enrollment declines primarily to affordability challenges. According to a Kaiser Family Foundation (KFF) analysis, the average deductible for ACA plans jumped 37% in 2026, reaching $3,786, the largest increase on record. Many enrollees encountered premium and out-of-pocket costs roughly twice what they faced the previous year, leading to widespread “sticker shock.”
Policy changes also contributed: the Trump administration ended a special enrollment period for low-income individuals and passed legislation expected to reduce ACA enrollment, such as the “One Big Beautiful Bill Act.” These changes, combined with subsidy cuts, have increased the financial burden for many marketplace consumers.
Some conservative analysts have cited concerns about purported enrollment fraud as partly responsible for previous high enrollment numbers, but their methodology and claims have been widely disputed by industry experts.
Implications for 2027 Premiums
Declining enrollment, especially among younger, healthier individuals, risks pushing up insurance premiums further, as insurers anticipate a sicker risk pool. Additionally, a growing share of enrollees are opting for bronze-level plans with lower monthly premiums but higher deductibles, potentially increasing unpaid medical costs that insurers must offset.
Regulatory uncertainties have complicated premium setting for 2027. For example, new rules finalized in May permitted higher deductibles and changes in provider networks, affecting insurers’ cost projections.
While a repeat of the 26% premium hike seen in 2026 is not expected, experts forecast continued double-digit increases next year due to the combined effects of reduced enrollment, costlier claims, and regulatory changes.
Why it matters
The decline in ACA marketplace enrollment reflects growing affordability challenges amid rising healthcare costs, threatening coverage stability for millions. Higher premiums and cost-sharing could further reduce insurance access, particularly for lower- and middle-income households. Insurers’ rate hikes will shape how affordable marketplace insurance remains, directly impacting public health coverage and political debates ahead.
Sources
This article is based on reporting and publicly available information from the following source:
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