红领巾瓜报

On April 15,听2026,听Wakely Consulting听Group, an 红领巾瓜报听company,听published听鈥�,鈥� the first听comprehensive nationwide look at听2026 enrollment trends in the听Affordable Care Act (ACA)听market.听While听the Centers for Medicare & Medicaid Services (CMS)听has released 2026 plan听selection听,听the Wakely report听addresses听who听retained听coverage听and who did not, what we still听don鈥檛听know, and what we should be watching for throughout the rest of the 2026 plan year.听

This article highlights key findings听in听the report, related state-level data,听impacts听and takeaways, and actions states and other听interest-holders听should consider as they look to mitigate further coverage losses and听address market stability听in听plan year 2027 and beyond.听

Key Findings听from the听ACA Marketplace Early Enrollment Trends听Report听

The听 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.听WNRAR includes data from over听75 issuers听representing听nearly 80 percent听of听enrollment听the individual market.听Key national findings听in听the report include:听

• Only 86% of enrollees paid their January 2026 premium.听
• State variation is significant, ranging from as low as鈥�63%鈥痯aid鈥痠n January to as high as鈥�99%.听
• The overall听average听enrollment鈥痙ecrease鈥痠s鈥痚stimated听to be between听17% and听26%鈥痩ower than 2025,听with morbidity projected to worsen听by听2.9鈥�6.5%.听

The report highlights听shifts听in plan听choice听activity听driven by affordability pressures,听which resulted in听considerable migration away from richer benefit plans to plans with lower premiums and higher out-of-pocket maximums. Examples include:听

• Silver plan enrollment fell听approximately听17% from 2025.听
• Bronze enrollment increased by more than 10%.听
• More than听13% of听2025听Gold plan enrollees听selected a lower听priced,听Bronze听tier plan听in 2026.听

The report also听demonstrated听the importance and value of outreach, operational excellence, and听state-level affordability听mitigation strategies. Examples include:听

• Enrollment decreases are lower in听states with听state-based marketplaces听(SBMs)听and expected to stay lower than Healthcare.gov states, largely听because of听proactive outreach and marketing initiatives,听lower net premium increases,听and state听affordability听programs.听
• 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听Early Enrollment Results听

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:听

• In听Georgia鈥攖he听only SBM without Medicaid expansion鈥攅nrollment听听27% from an estimated听1.3听million in听April听2025 to approximately听950,000听in听April 2026.听
• In听New听Jersey鈥攁听state听with state-funded premium subsidies,听a reinsurance program, and a mandate听that听residents have health听insurance鈥攅nrollment has听听by more than 11%听since听April 2025.听
• In听California鈥攁nother state with premium subsidies,听facilitated听enrollment,听and an individual mandate鈥攅ffectuated听enrollment听听by 7%听from February 2025 to February 2026.听
• Overall, SBMs are听听that coverage drops听were听24% higher from January to March 2026 than听during听the same period in 2025 and that听the rate of plan shifting from Silver to Bronze听increased听significantly,听quadrupling听in six states.听

Downstream Impact on听Healthcare Access听and Uncompensated Care听

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.听

Looking Ahead听

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,听there are听potential federal听changes such as expanded availability of catastrophic plans, the introduction of non-network plans, and听additional听eligibility changes,听which听could put further strain听on 础颁础听惭补谤办别迟辫濒补肠别 operations and the individual听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听provide consumers with affordability relief听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听

红领巾瓜报, Inc. (红领巾瓜报),听and Wakely听colleagues听are closely tracking federal policy activity and state actions to address these challenges. Our experts support states,听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听improve affordability and stability听as听it听evolves听in the coming months and years.听

Contact听Lina Rashid,听Zach Sherman, or听听with questions about the report and听to discuss opportunities to address the trends and forthcoming changes in the market.听

To read more about the听changes ahead, see the following reports:听

• 2027 Proposed NBPP: Analyzing State and Consumer Impacts听
• Medicaid Changes in the OBBBA and Implications for the Marketplace and Individual Market in 2027听
• 听

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

Q: As CMS begins releasing draft payment rules for 2027, what stands out most to you from a听budgetary听perspective?
Rachel: Timing and uncertainty really stand out. These policies don鈥檛 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.听

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

Rachel:听Historically, many MA plans have followed the听IPO听policy听even though they听weren鈥檛听required to听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听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.听

Q: Where do you see the biggest potential impact for Medicare Advantage?
Rachel:听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听anticipates听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听small changes听in听benchmark growth can affect plan revenue, rebates, and benefit flexibility.听

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

Q: How does this uncertainty affect provider planning,听especially for听hospitals?
Rachel:听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听share in听savings through those mechanisms. So,听while there may be pressure on inpatient revenue,听it鈥檚听not necessarily a one听directional loss.听

Q: Does that mean the overall impact may be less dramatic than it appears?
Rachel: Potentially, yes鈥攅specially 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.听The redistribution of dollars through shared savings and quality bonuses can offset some of that pressure. That鈥檚 why understanding contract structure is just as important as understanding the policy itself.听

Q: What about quality and patient safety as procedures move to lower听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鈥檛 yet seen specific quality safeguards tied to the IPO list changes, but I would expect more discussion in the forthcoming proposed rules.听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.听

Q:听What steps听do听you recommend to听stakeholders听to听prepare for the final rule and for 2027?
Rachel:听Modeling helps organizations understand the range of听possible outcomes听rather than betting on a single assumption.听We鈥檙e听looking at different听utilization听scenarios, site听of听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听doesn鈥檛听eliminate听uncertainty, but it helps organizations make informed decisions.听

Q: If you could change one thing about how these policies are rolled out, what would it be?
Rachel:听Transparency. The more clarity CMS can provide around cost projections and assumptions鈥攅specially those affecting benchmarks鈥攖he 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.听

红领巾瓜报鈥檚 Medicare Practice Group Can Help听

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

For听additional听insights, listen to Rachel Stewart听and Zach Gaumer听on听红领巾瓜报鈥檚 Vital Viewpoints听podcast.听Learn more about听our听Medicare services and solutions.听