ACA 2026 in review: What enrollment data, 2027 rate filings, and the courts have settled

Three things happened between May and August of 2026 that changed what advisors can say with confidence about the individual market.

CMS finalized the rules for 2027, and a federal judge paused most of them nine weeks later. Insurers filed 2027 rates across all fifty states. And CMS released effectuated enrollment data, which counts who actually paid a premium rather than who clicked through a plan selection. That last dataset revised the story of 2026 substantially, and not in the direction the early coverage suggested.

The result is a market that looks different depending on which number you pick up. Sign-ups fell by about a million. Paid enrollment fell by nearly three million. Premiums rose sharply, but the amount households actually paid rose less than projected, because people bought thinner coverage instead of dropping out.

This piece walks through how ACA rates get built, what the 2026 data now shows, what carriers are requesting for 2027, and which rules are actually in force heading into renewal season.

How ACA insurance rates are set

Understanding ACA rates starts with understanding the timeline. Each spring, insurers develop rate proposals based on claims data and cost projections. By early summer, those proposals are filed with state Departments of Insurance and/or CMS. Regulators then spend the summer reviewing filings, requesting changes, and approving final rates, which are published in October before Open Enrollment begins. The new plan year kicks off in January.

The rate development process itself involves four key steps:

1. Insurers project medical and drug costs, utilization, and risk mix

2. They file those rates with actuarial justification

3. State or federal regulators review to ensure rates are adequate, not excessive, and not discriminatory

4. Results are posted publicly, particularly for increases above 15%

What regulators are ultimately reviewing is a snapshot of market conditions at a specific moment in time. Those conditions can shift significantly from year to year depending on several forces, including:

• The health of the risk pool (younger versus older enrollees)

• Medical inflation and provider reimbursement trends

• Prescription drug costs and the innovation pipeline

• Federal or state policy changes including subsidies, reinsurance, and market rules

Track proposed 2027 ACA rate filings by state and carrier.

One wrinkle worth noting for this cycle. The 2027 Notice of Benefit and Payment Parameters was not finalized until after some insurers had already prepared their 2027 filings, and several carriers flagged that the late finalization introduced uncertainty into their pricing.⁴ That means some carriers priced their 2027 plans before they knew what the final rules would require. 

Why 2026 sign-up numbers understated the coverage losses

Early analysis focused on plan selections, which fell by roughly a million. That number understated the damage considerably.

Effectuated enrollment counts only people who paid their premiums. It tells a different story:

• February effectuated enrollment came in at 19.2 million, down from 21.8 million in 2025, a 12% decline¹

• HHS reported the year-over-year drop at close to three million people¹

• The national effectuation rate fell from 90% to 83%, the first time below 90% since 2019¹

State-level results reveal what actually drove coverage losses

Every state except New Mexico lost enrollment. New Mexico, the only state to fully replace the expired federal enhanced tax credits with state-funded subsidies, grew 14%.¹

The structural split was significant:

• States running their own marketplace platforms: 6% decline¹

• States on HealthCare.gov: 15% decline¹

Effectuation rates diverged even further:

• Lowest: Mississippi at 61%, meaning nearly two in five people who signed up did not keep coverage past January¹

• Also under 70%: South Carolina, Louisiana, Indiana, Oklahoma¹

• Above 95%: New Mexico, California, Nevada, Vermont, Idaho¹

For advisors working national accounts, sign-up counts no longer tell you how many people actually ended up with coverage. South Carolina plan selections fell 7% while effectuated enrollment fell 29%. Michigan and Minnesota showed similar divergence.¹

How consumers absorbed the subsidy loss

Enrollees who stayed generally traded coverage depth for a manageable monthly payment.

• Average premium payments net of subsidies rose 58%⁴

• Silver enrollment fell from 57% to 43%²

• Bronze enrollment rose from 30% to 40%²

• Average deductibles rose 37%, or $1,027 per person, to a record $3,786²

That buy-down is why the realized premium increase landed below the doubling early projections suggested. It also means coverage got thinner in ways a premium figure alone won't show a client.

The year isn't finished. KFF projects enrollment could fall to between 16.5 million and 17.5 million over the course of 2026, based on how many people are likely to keep up with premiums.²

Carrier participation is thinning, county by county

Most insurers kept selling on the exchanges in 2026 rather than pulling out, which is better than many predicted. But the direction has turned.

• Average issuers per state fell from a record 9.6 in 2025 to 9.0 in 2026³

• 18 states saw a net decrease³

• Aetna exited ahead of 2026; Cigna has announced its intent to exit for 2027, along with several smaller carriers⁶

Insurers participate county by county, not statewide, so a state-level carrier count can look healthy while individual counties are down to one option. Pull participation for the counties your clients actually employ people in.

What insurers are requesting for 2027, and what those numbers mean

Across 276 insurers with publicly available filings in all 50 states and DC, the median proposed increase for 2027 is 15%.⁴ That makes two consecutive years of double-digit increases.

Context for the number:

• For the 2026 plan year, the median proposed change was 18% and the median finalized change was 20%⁴

• Proposed 2027 changes range from a 1% decrease to a 54% increase⁴

• Roughly 63% fall between 10% and 25%; 51 insurers requested more than 25%⁴

• A narrower set of 77 insurers across 16 states and DC, used for the cost-driver analysis, shows a median of 14%⁴

• If these hold, typical premiums for participating insurers will have risen by more than a third across two years⁴

Note that proposed rates rose two points during review last cycle. The 15% is a floor as much as a forecast.

The four cost drivers insurers named in their 2027 filings

Underlying medical trend. The median change in the cost of medical care and prescription drugs came in at 10% for 2027, above the 8% average of recent years.⁴ Carriers point to provider contract increases, general economic inflation, and healthcare labor shortages.

Claims severity. Several insurers describe a measurable shift toward higher-acuity billing. One Massachusetts carrier documented changes in inpatient and outpatient billing practices that increased provider revenue without a corresponding change in care delivery.⁴

Specialty drugs. GLP-1 pressure continues, though carriers are responding differently. Some dropped weight-loss coverage while retaining diabetes indications and expect a downward effect on 2027 rates. Others report gross costs tripling over two years.⁴ 

Risk pool morbidity. The enhanced tax credit expiration added roughly 4 percentage points to 2026 rates. Insurers are now building 2027 rates on top of that degraded pool, projecting another 4 points from the same dynamic.⁴

What two years of increases look like for an unsubsidized household

The compounding effect is the number to bring into client conversations.

A 40-year-old in Indianapolis earning $65,000:⁴

• $316 per month with enhanced credits⁴

• $477 in 2026⁴

• $546 in 2027 if filed rates are approved⁴

That is a 41% increase in what the household actually pays, across two years.⁴

The 2027 Payment Notice was finalized in May, then paused in July

CMS issued the 2027 Notice of Benefit and Payment Parameters final rule on May 15, 2026, effective July 20.⁵ On July 16, four days before that effective date, Judge Brendan Hurson of the U.S. District Court for Maryland stayed key provisions in a case brought by Doctors for America, the Main Street Alliance, three cities, and Pima County, Arizona.⁶ Eight provisions were paused.⁷

Advisors need to hold three categories separately.

Stayed pending litigation

These will not take effect unless the court rules for the administration:⁶

• The annual failure-to-reconcile policy⁶

• Additional income verification when self-reported income falls below 100% FPL or tax data is unavailable⁶

• Expanded pre-enrollment verification across a wider set of special enrollment periods⁶

• Permitting certain bronze plans to set annual cost-sharing limits as high as 130% of the statutory maximum⁶

• Eliminating the standardized plan requirement for federally facilitated marketplace insurers⁶

• Allowing states to conduct network adequacy reviews otherwise performed by CMS⁶

• Expanding hardship exemption eligibility for catastrophic coverage⁶

• The pathway for non-network plans to qualify as marketplace coverage⁷

Finalized and not challenged

These are in effect:⁵

• Multi-year catastrophic plan terms of up to 10 consecutive plan years⁵

• Prohibition on counting routine adult dental services as an essential health benefit⁵

• Tighter state defrayal obligations for state-mandated benefits, beginning PY 2028⁵

• Permanent rescission of fixed-dollar and gross percentage premium payment thresholds⁵

• Expanded marketing restrictions on agents, brokers, and web-brokers⁵

• Lower 2027 user fees: 1.9% for the federally facilitated exchange, 1.5% for state-based exchanges on the federal platform⁵

• The essential community provider contracting threshold holds at 35%; CMS declined to lower it to 20%⁵

• Methodological changes to the premium adjustment percentage, which the court permitted to proceed⁶ 

Never carried forward into the 2027 rule

Two policies that circulated widely in 2025 commentary are gone. The administration did not reissue:⁶

• The shortened open enrollment period⁶

• Widened actuarial value ranges⁶

• The $5 monthly premium for fully subsidized auto re-enrollees⁶

• The past-due premium requirement⁶

• Elimination of the 60-day data-matching extension⁶

• Key portions of the 2026 rule containing these provisions were stayed in 2025 and vacated in June 2026. That vacatur is under appeal.⁶ 

Effective dates that are easy to get wrong

Several provisions do not land in the 2027 plan year even though they appear in the 2027 rule:⁵

• Non-network plan certification, if it survives litigation, begins PY 2028⁵

• Bronze cost-sharing changes were set for PY 2027; catastrophic cost-sharing changes for PY 2028⁵

• The standard eligibility application and consent form applies to plan years beginning on or after January 1, 2028⁵ 

Statutory changes arrive regardless of how the litigation resolves

Congress wrote several restrictions into law, which puts them outside the reach of these cases:

• The prohibition on the 150% FPL special enrollment period continues past PY 2026 under section 71304 of the Working

• Families Tax Cut legislation⁵

• Subsidy eligibility ends for refugees, asylum seekers, and people with Temporary Protected Status starting in 2027⁶

• The annual file-and-reconcile requirement and several verification mandates begin in 2028⁶

The court itself noted that many of the plaintiffs' arguments would be neutralized by 2028.⁶ 

Where the three legislative questions landed

PBM reform passed. Provisions from the PBM Reform Act were enacted within H.R. 7148, the Consolidated Appropriations Act of 2026, signed February 3, 2026.⁹ Most requirements, covering transparency reporting, rebate pass-through for commercial and ERISA plans, and audit rights, take effect in 2028 and 2029.⁹ CBO scored the package at a $2.12 billion federal deficit reduction over ten years.⁸

Enhanced tax credit restoration did not. The House passed a three-year extension 230 to 196 in January, with 17 Republicans joining, but the Senate has not acted.¹⁰ Competing proposals failed in December 2025, neither reaching 60 votes.¹¹

Cost-sharing reduction payments remain unfunded. The alternative that would have funded them failed in the same December votes.¹¹ Silver loading continues to absorb the gap, which is why benchmark silver premiums and filed average rate changes are not directly comparable figures.

CHOICE arrangement legislation has passed the House inside broader packages but has not received Senate committee consideration.

Three things to reassess before renewal conversations

Look at income ranges, not headcount. The pressure is concentrated on households earning above 400% of the federal poverty level, roughly $63,000 for a single person. They lost subsidy eligibility entirely when the enhanced credits expired, and they now face a second straight double-digit premium increase with no assistance to cushion it. If a meaningful share of a client's workforce earns above that line, individual market costs start affecting what they need to pay people, not just what they offer them.

Geography. Effectuation rates diverged by more than 30 points across states this year. Expect meaningfully different retention behavior in Mississippi or Oklahoma than in California or Vermont, and set client expectations accordingly.

Durability of your own guidance. The regulatory environment will stay unsettled through at least the 2028 plan year. Advice built on a specific rule taking effect on a specific date carries real risk right now. Advice built on statutory changes, which are not subject to this litigation, carries much less.

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Whether your clients are facing steep renewal increases, managing a distributed workforce, or exploring defined contribution benefits for the first time, Take Command can help you find the right path forward. Talk to a Take Command expert.

References

1. KFF, "How Has ACA Marketplace Enrollment Changed Across States in 2026?" July 28, 2026

2. HFMA, "ACA marketplace enrollment decline puts coverage affordability in focus," June 29, 2026

3. KFF, "How Has Insurer Participation in the ACA Marketplaces Changed in 2026?" June 11, 2026

4. Peterson-KFF Health System Tracker, "How much and why ACA Marketplace premiums are going up in 2027," updated August 3, 2026

5. CMS, "HHS Notice of Benefit and Payment Parameters for 2027 Final Rule" fact sheet, May 15, 2026

6. HFMA, "Judge blocks key ACA marketplace rule provisions for 2027," July 17, 2026

7. American Hospital Association, "District court pauses 8 provisions from 2027 notice of benefit and payment parameters final rule," July 20, 2026

8. KFF, "What to Know About Pharmacy Benefit Managers (PBMs) and Federal Efforts at Regulation," updated February 9, 2026

9. Pharmacy Times, "PBM Reform Within 2026 Appropriations Bill Signed Into Law," February 2026

10. NBC News, "House votes to revive Obamacare funds as senators plot a scaled-back bill," January 8, 2026

11. Health Affairs Forefront, "Senate Fails To Extend Enhanced ACA Subsidies; Focus Turns To House," December 2025