Explore how 2026 ACA Marketplace enrollment shifts, plan selection trends, and the 2027 NBPP changes are impacting affordability, market stability, and state strategies.
Recent Health Management Associates (HMA) webinars and reports discussed that Affordable Care Act (ACA) Marketplace enrollment trends are evolving rapidly and the takeaways go beyond total enrollment numbers. In addition in May, the Centers for Medicare and Medicaid Services (CMS) finalized the 2027 Notice of Benefit and Payment Parameters (NBPP), introducing new flexibility for plans and states alongside stronger program integrity requirements.
To understand how these changes are reshaping the ACA Marketplace, Andrea Maresca spoke with Zach Sherman, Managing Director for Coverage Policy and Program Design at HMA as well as Michael Cohen, PhD, Principal at Wakely, and Liz Wroe, Principal at Leavitt Partners, both HMA companies.
Q: The recent Wakely analysis has been central to understanding what’s happening with ACA enrollment. What should people be paying closest attention to?
Michael Cohen: The key takeaway is that ACA Marketplace trends are about much more than the enrollment numbers. The plans consumers choose, how long they maintain coverage over the course of 2026, and the evolving picture of the morbidity and demographics of the enrolled population are all critical factors for understanding the ACA Marketplace.
Our recent Wakely analysis found that only about 86 percent of enrollees paid their firstpremium in 2026. That’s a strong indicator that affordability pressures are already affecting coverage stability.
Q: Where are these enrollment changes showing up most clearly?
Michael Cohen: One data point that stood out is the number of new consumers in 2026, which was down 13 percent compared with prior years.
The impact also shows up in coverage losses and consumer plan selection. Some consumers are dropping coverage altogether, while others are making tradeoffs to stay covered. These consumers are moving to lower-premium products—particularly from silver to bronze plans—which offer less robust coverage and higher out-of-pocket costs. Both trends matter, especially when thinking about access and financial risk.
Q: How are enrollment shifts affecting broader ACA Marketplace stability?
Zach Sherman: It varies by state, but there are notable trends. States that are using the Federally Facilitated Exchange (FFE) and expanded Medicaid saw the largest enrollment declines.
Notably, non-expansion states on the FFE significantly outperformed expansion states. This was surprising because, with enhanced subsidies ending, the biggest net premium hit consumers would feel is at the lowest income levels, yet that’s where we saw most enrollment growth.
Across the individual states, the enrollment shifts have real implications for stability. When healthier individuals leave the market—or shift to less comprehensive coverage—it can put pressure on premiums and risk pools. Issuers are taking this information to begin to make estimates for their 2027 pricing and what this means for their 2026 performance.
At the same time, CMS is introducing new flexibilities in the final 2027 Notice of Benefit and Payment Parameters.
Q: What are the most important changes in the 2027 final rule?
Zach Sherman: Broadly, the rule makes a clear push toward increased flexibility for consumers, plans, and state regulators.
One of the categories of changes is around expanded availability of lower premium plans with higher out-of-pocket costs. For example, catastrophic plans can now be offered for up to 10 years.
CMS also removed certain requirements for standardized plans and relaxed limits on non-standard plan offerings. That gives issuers more room for plan design innovation, but it also means a more complex landscape and plan selection experience for consumers.
One of the most notable changes is the introduction of non-network plans as qualified health plans. These plans don’t rely on traditional provider networks, which could lower costs while introducing new considerations for access and consumer experience.
We’re seeing a shift toward allowing more tailored options and potentially less standardized marketplace programs. It will require a different approach from regulators, and it creates a different type of experience for consumers.
Q: CMS is intensely focused on addressing fraud, waste and abuse. How is that playing out in the Marketplace program?
Zach Sherman: Program integrity is a central theme in the 2027 final rule, too. It includes stronger eligibility verification, increased oversight of brokers and marketing practices, and new safeguards to reduce improper enrollments. So while there’s more flexibility in plan design, CMS is pairing it with more scrutiny on how the system operates.
Q: Where do states fit in all of this?
Zach Sherman: The final rule gives states more authority in key areas, including oversight of plan network adequacy and essential community provider compliance. We’re deep into discussions with states and health plan issuers about the changes they’re interested in exploring for their state. States will have to decide how to use that flexibility to balance affordability, access, and stability.
Although many of the provisions take effect in the 2027 plan year, regulators and plans are receiving this information fairly late in the cycle which will make it difficult to incorporate some of the flexibilities. We’re anticipating robust discussions to continue next year and expect to see more variation starting in plan year 2028.
Differences and Alignment in Federal ACA Marketplace Policy Discussions
Q: Stepping back from the 2027 NBPP, what should interest-holders know about the evolution of the broader policy landscape?
Liz Wroe: Members of Congress will need to see the 2027 rates being filed before they consider taking action. Even then, there’s no consensus on several key issues that prevented a bipartisan deal to bring back enhanced subsidies in 2025.
Instead everyone has transitioned to a larger affordability conversation, and we’ll spend this year working on the policies with a goal of moving forward in 2027.
There are different approaches to affordability and coverage that are driven by fundamentally different philosophies on how to structure the market. Some proposals focus on expanding subsidies, reducing cost sharing, and strengthening ACA protections. Others emphasize consumer-directed models like defined contributions, health savings accounts, and expanded use of ICHRAs [Individual Coverage Health Reimbursement Accounts] as well as broader access to lower premium plans.
There are also several areas of bipartisan alignment. Prior authorization reform is a big one. There’s broad agreement that the current system creates administrative burden and delays in care.
We’re also seeing common interest in policy approaches to strengthen medical loss ratio [MLR] requirements, expand price transparency, and address provider consolidation.
Even if there is divided government after the November elections, these are areas where policy action may be more likely. States, health plans, providers, and other interest holders will want to monitor these issues now for signals of what may move forward later this year or in the next Congress.
Stakeholder Opportunities to Inform Marketplace Programs
Q: What should stakeholders be focused on right now?
Michael Cohen: For issuers, it’s about understanding how these changes affect pricing, enrollment, and risk. There’s more uncertainty in how plans should be priced.
Zach Sherman: For states, the focus should be on strategy. The choices they make now on plan oversight, market structure, and consumer protections will shape outcomes for several years. Additionally, there were several proposed Marketplace policies that CMS did not finalize in the 2027 rule—State-Based Exchange Enhanced Direct Enrollment Model—that CMS is likely to revisit in future rules, including the 2028 NBPP.
Liz Wroe: Broadly, stakeholders should recognize that we’re in a transition period. The market is evolving, and policy is still catching up.
Connecting the Dots: Enrollment, Rules, Regulators, and the ACA Marketplace
For stakeholders across the healthcare landscape, navigating this environment requires both technical expertise and strategic insight.
HMA works across policy, actuarial, and operational domains to help states, health plans, and other stakeholders translate these developments into actionable strategies—whether that means evaluating market risk, designing programs, or preparing for future policy scenarios.
To explore these issues in more detail, access HMA’s webinar discussions and briefs, including:
