ACA Marketplace: The Real Enrollment Story

May 15, 2026  |  Health Insurance, Exchange, ACA, CMS

Mike Rawaan, Founder and Managing Director

ACA Marketplace: The Real Enrollment Story

Fierce Healthcare published an article on May 12 about internal documents obtained by the news outlet, NOTUS, which concludes that 1 in 5 marketplace enrollees dropped their coverage in 2026. The official 2026 Open Enrollment Period from CMS, published on March 27 of this year, offered a more encouraging outlook on enrollment numbers. It’s difficult to access why there was such a drop off without the data, but here are some possible answers:

• As Stacy Mays pointed out in her LinkedIn post, the value proposition of the plans available on the marketplace have deteriorated badly – and I completely agree!

• Ms. Mays also alluded to many enrollees automatically re-enrolled in 2026, betting on tax credits to help them pay the cost.

• Another possibility is that many enrollees underestimated the premium hikes, and they cancelled their plan once they saw the new premiums

• The emergence of alternatives – primary care + catastrophic coverage or just self-pay as needed

According to the CMS PUF file published in March:

• Total 2026 enrollment closed at 23.1 million - a 4.9% decline from the record 24.3 million in 2025 Healthcare Financial Management Association

• New enrollees fell to 3.6 million (down ~500K year-over-year); auto re-enrollees dropped 19% to 8.8 million; active re-enrollees rose 15% to 10.7 million Healthcare Financial Management Association

• The share receiving subsidies fell from 92% in 2024–25 to 87% in 2026, and average net premiums jumped from $74/month to $96/month for subsidized enrollees Healthcare Financial Management Association

• Bronze plan selections surged from 30% to 40% of all selections; silver plan enrollment (the only tier eligible for cost-sharing reductions) dropped from 51% to 37% Healthcare Financial Management Association

• CMS attributed a large portion of the auto-enrollment decline to enforcement actions against improper enrollments, terminating coverage for nearly 1.5 million people found ineligible or enrolled without authorization Fierce Healthcare

What the NOTUS/Fierce Report Reveals (Post-OEP Attrition):

• More than 21% of HealthCare.gov enrollees were dropped after failing to pay their first premium - compared to just 12% in the same window in 2025 Fierce Healthcare

• Total ACA enrollment has since fallen to roughly 19 million - approximately 3 million fewer than one year ago NOTUS

• State-based exchanges fared better, losing only 8% since the start of the year - roughly half the federal rate — with several states offsetting losses by supplementing expiring federal subsidies with state funds NOTUS

• BCBS reported a 13.5% drop among its marketplace enrollees, with those leaving most often ages 25–40 in silver plans NOTUS

• Cigna announced it will exit the ACA market entirely in 2027 Fierce Healthcare

The Gap Between the Two Sources: The CMS PUF captures plan selections — who signed up. It does not capture effectuated enrollment — who actually paid and activated coverage. The NOTUS data fills that gap. The 23 million headline becomes closer to 19 million in practice. That's a ~17% real-world contraction, with Wakely projecting it could reach 26% by year's end.

What This Means for Health Plans:

First, ignore the CMS reports and look at your own enrollment.  What was your YOY variance in Q1 enrollment for your exchange / ACA book of business?

The drop in enrollment might be the tip of the iceberg. It’s more important – and impactful to your financials – to understand WHO disenrolled.  If healthier individuals are the ones exiting, the overall ACA morbidity could increase between 2.9% and 6.5% in 2026, and you won't see the full claims picture until mid-summer. Enrollees who are still paying premiums are disproportionately older, sicker, and on bronze plans with high deductibles, which means more cost-sharing friction, more delayed care, and more adverse selection pressure heading into 2027 rate-setting season. Healthcare Dive

BCBS reported enrollment declines exceeding 30% in several markets. That's not a blip - that's a structural market shift. Plans that built network density, care management capacity, and star/quality programs around a certain volume now have a math problem. The Hill

The fraud narrative CMS leadership is pushing doesn't hold. Sources inside the agency told NOTUS that CMS is pointing to fraud enforcement as the reason for higher drop rates; however, that's unlikely to be the primary driver. The real explanation is simpler and more consequential: people couldn't afford the first premium check when enhanced subsidies expired. Fierce Healthcare

For plans still in the exchange market, 2027 pricing decisions are currently being made under maximum uncertainty about who remains in the pool and what they'll cost. Underprice and you absorb the adverse selection. Overprice and you accelerate the exit of the remaining healthy members. There's no clean answer. But the plans that understand their actual effectuated enrollment - not the OEP selection count - are the ones who will price correctly and survive this cycle. It’s time to do some homework.

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