The Affordable Care Act (ACA) marketplace entered 2026 facing a different environment from recent years. Enhanced premium tax credits that had expanded affordability since 2021 expired at the end of 2025, leading to higher premium payments and shifts in plan selection across the country.
At the same time, the Centers for Medicare & Medicaid Services (CMS) finalized a broad set of rules for the 2027 plan year. The changes include new eligibility verification requirements, expanded flexibility for insurers, and new coverage options that federal officials say are intended to strengthen program integrity and increase consumer choice.
Enrollment Declines as Premiums and Deductibles Increase
Early indicators show that ACA marketplace participation is falling after several years of record growth. According to KFF, open enrollment plan selections declined by more than one million people to 23.1 million in 2026, representing the largest single-year drop since the ACA marketplaces were launched. The organization estimates that average monthly effectuated enrollment (people who actually pay their premiums and maintain coverage) could fall to roughly 17.5 million during 2026.
Premium payments have increased sharply for many consumers. According to KFF, the average monthly premium payment rose from $113 to $178, a 58% increase compared with 2025. At the same time, consumers increasingly shifted into lower-premium bronze plans, which generally carry higher deductibles.
That trend contributed to a substantial increase in out-of-pocket exposure. KFF reported that average marketplace deductibles rose by 37%, increasing from $2,759 to $3,786 in 2026. The share of consumers selecting bronze plans climbed from 30% to 40% of total plan selections, while silver-plan enrollment fell to 43%.
According to reports, insurers are closely monitoring whether consumers continue making premium payments throughout the year. Analysts said rising costs may disproportionately affect younger and healthier enrollees, raising concerns about the overall risk profile of the insurance pool.
New CMS Rules Expand Flexibility While Tightening Oversight
CMS finalized its 2027 Payment Notice in May, introducing a series of policy changes affecting marketplace operations, plan design, and eligibility verification. According to CMS, the rule reduces federal exchange user fees, reinstates pre-enrollment verification requirements for certain special enrollment periods, and requires additional income documentation in specific circumstances.
The agency said the changes are designed to prevent improper enrollments, strengthen oversight of agents and brokers, and ensure that premium subsidies are directed to eligible individuals. CMS Administrator Dr. Mehmet Oz stated that the rule aims to strengthen eligibility checks and expand affordable coverage options.
The final rule also removes requirements for insurers using HealthCare.gov to offer standardized plan options and creates a pathway for certain plans without traditional provider networks to qualify for marketplace certification. According to a KFF Health News analysis, some future plans could operate without fixed networks of doctors and hospitals, requiring consumers to locate providers willing to accept the insurer’s payment terms.
Another major change involves out-of-pocket limits. Beginning in 2027, insurers may offer certain bronze plans with maximum out-of-pocket costs up to 30% higher than standard limits. Catastrophic plans will also be affected under later provisions, with higher cost-sharing thresholds and expanded eligibility pathways for some consumers.
