ACA Signups

2027 Rate Changes - Iowa +6.7% for unsubsidized indy market enrollees; Medica is out

Charles Gaba — Mon, 13 Jul 2026 20:35:53 +0000

Mon, 07/13/2026 - 4:35pm

Medica will no longer offer individual marketplace plans in Iowa, Kansas and Oklahoma, effective January 1, 2027.

The decision affects about 4,000 members in Iowa, 600 members in the Kansas City area in Kansas, and 8,400 members in Oklahoma, the company confirmed to Becker’s. The insurer will continue to offer marketplace coverage in Minnesota, Missouri, Nebraska, North Dakota and Wisconsin.

“Members currently enrolled in Medica individual products in these states will continue to receive benefits until their renewal date,” a Medica spokesperson said. “Medica’s strategic focus is to ensure we remain competitive in markets where we can deliver value by simplifying offerings, reducing overlap, and prioritizing high-value provider partnerships.”

This puts Iowa's total ACA-compliant individual market at around 104,000 people total as of spring 2026, with preliminary weighted average 2027 rate increases of around 6.7%...the second-lowest statewide average I've seen so far, after Vermont's 6.5% average:

Avera Health Plans:

1. SCOPE AND RANGE OF RATE INCREASE

Avera Health Plans, Inc. (Avera) is requesting a rate increase for the Avera MyPlan individual products for Iowa with an effective date of January 1, 2027. The requested overall rate increase impacts approximately 438 members. The rate increase being requested for the Avera MyPlan products is 14.8% averaged across all members. Rate changes vary by plan due to changes in cost sharing parameters (e.g., deductible, coinsurance, copays) relative to 2026 cost sharing parameters, ranging from 12.3% to 21.7% by plan.

2. FINANCIAL EXPERIENCE

There is no historical financial experience to report as Avera entered the Iowa individual market on January 1, 2026. The financial experience for Avera’s South Dakota individual ACA-compliant experience, which supports manual rate projections in Iowa, was unfavorable in 2025 relative to the 2024 experience used to develop 2026 rates.

3. CHANGES IN MEDICAL SERVICE COSTS AND TREND ASSUMPTIONS

To capture the increasing cost and utilization of medical services, projections from manual rate experience assume 6.7% annual trend. This assumption is based on analysis of regional and national trends and actuarial judgment.

4. CHANGES IN BENEFITS

Avera will make cost sharing modifications by plan to comply with the final 2027 Actuarial Value Calculator and based on 2027 strategic considerations. To the extent the plan changes lead to a higher or lower level of benefit richness, the premium rates would increase or decrease, respectively.

5. ADMINISTRATIVE COSTS AND ANTICIPATED PROFITS

Avera is targeting a loss ratio of 86.5% for its individual block of business in January 2027. This loss ratio allows 13.5% for total health plan administrative costs, taxes, fees, and anticipated profits.

6. EXPIRATION OF EXPANDED ADVANCE PREMIUM TAX CREDIT SUBSIDIES

Avera expects the expiration of expanded Advance Premium Tax Credit subsidies will result in higher market morbidity due to the anticipated mix of enrollees remaining in the market.

IOWA TOTAL CARE:

Iowa Total Care is filing rates for the individual block of business, effective January 1, 2027. This document is submitted in conjunction with the Part I Unified Rate Review Template and the Part III Actuarial Memorandum.

This information is intended for use by the Iowa Insurance Division, the Center for Consumer Information and Insurance Oversight (CCIIO), and health insurance consumers in Iowa to assist in the review of Iowa Total Care’s individual rate filing.

The results are actuarial projections. Actual experience will differ for a number of reasons, including population changes, claims experience, and random deviations from assumptions.

In 2025, earned premium was $517.11 per member per month (PMPM). Incurred claims in 2025 were $363.50, or 70.29% of premium. Netting risk adjustment from the claims results in an estimated loss ratio (incurred claims net of estimated risk adjustment transfers, divided by earned premiums) of 80.67%. We expect unit costs to increase for 2027. Further, we have updated underlying experience for the single risk pool, expected administrative expense, and assumptions for federal risk adjustment. These factors, as well as changes to the assumed morbidity of the single risk pool and medical trend, result in a premium rate increase.

Medical trend, or the increase in health care costs over time, is composed of two components: the increase in the unit cost of services and the increase in the utilization of those services. Unit cost increases occur as care providers and their suppliers raise their prices. Utilization increases can occur as people seek more services than before. Additionally, simple services can be replaced with more complex services over time, which is known as service intensity trend. An example of service intensity trend would be the replacement of an X-ray with an MRI scan. Replacing the service with a more intense service causes the total cost of medical services to increase.

The proposed rate change of 16.8% applies to approximately 6,982 individuals. Iowa Total Care’s projected administrative expenses for 2027 are $100.80 PMPM. Administrative expense does not include $19.87 for taxes and fees. The historical administrative expenses for 2026 were $81.57 PMPM, which excludes taxes and fees. The projected loss ratio is 81.0% which satisfies the federal minimum loss ratio requirement of 80.0%.

OSCAR INSURANCE CO:

1. Scope and Range of Rate Increase

The purpose of this document is to present rate change justification for Oscar Insurance Company, Inc (Oscar’s) Individual Affordable Care Act (ACA) products, with an effective date of January 1, 2027, and to comply with the requirements of Section 2794 of the Public Health Service Act as added by Section 1003 of the Patient Protection and Affordable Care Act (ACA).

Using in-force business as of March 2026, the proposed average rate increase for renewing plans is 11.9%. Rate increases vary by plan and range from 4.6% to 28.2% due to a combination of factors including shifts in benefit leveraging and cost-sharing modifications and network changes. This rate increase is absent of rate changes due to attained age. There are 11,971 current members impacted by this rate increase.

2. Reason for Rate Increase(s)

The significant factors driving the proposed rate change include the following:

Medical and Prescription Drug Infl ation and Utilization Trends
The projected premium rates reflect the most recent emerging experience which was trended for anticipated changes due to medical and prescription drug inflation and utilization.

Administrative Expenses, Taxes and Fees, and Risk Margin
Changes to the overall premium level are needed because of required changes in federal and state taxes and fees. In addition, there are anticipated changes in both administrative expenses and targeted risk margin.

Prospective Benefit Changes
Plan benefits have been revised as a result of changes in the Center for Medicare and Medicaid Services (CMS) Actuarial Value Calculator and state requirements, as well as for strategic product considerations.

Anticipated Changes in the Average Morbidity of the Covered Population
Changes to the overall premium level are needed because of anticipated changes in the underlying morbidity of the projected marketplace.

Anticipated Changes in the Network Configuration
Changes to the overall premium level are needed because of anticipated changes in the underlying network configuration and associated unit costs.

UNITEDHEALTHCARE OF THE RIVER VALLEY:

Scope and Range of the Rate Increase

UHCPRV is filing 2027 rates for individual products. The proposed rate change is 11.77% and will affect 546 individuals. The rate changes vary between 9.66% and 12.53%. Given that the rate changes are based on the same single risk pool, the rate changes vary by plan due to plan design changes.

Financial Experience of the Product

The premium collected in plan year 2025 was $3,966,129. Incurred claims during this period were $3,070,089 and UHCPRV expects payments of $42,830 for risk adjustment. The loss ratio, or portion of premium required to pay medical claims, for plan year 2025 is 78.49%.

Changes in Medical Service Costs

There are many different healthcare cost trends that contribute to increases in the overall U.S. healthcare spending each year. These trend factors affect health insurance premiums, which can mean a premium rate increase to cover costs. Some of the key healthcare cost trends that have affected this year’s rate actions include:

Increasing cost of medical services: Annual increases in reimbursement rates to healthcare providers, such as hospitals, doctors, and pharmaceutical companies.

Increased utilization: The number of office visits and other services continues to grow. In addition, total healthcare spending will vary by the intensity of care and use of different types of health services. The price of care can be affected using expensive procedures such as surgery versus simply monitoring or providing medications.

Higher costs from deductible leveraging: Healthcare costs continue to rise every year. If deductibles and copayments remain the same, a higher percentage of healthcare costs need to be covered by health insurance premiums each year.

Impact of new technology: Improvements to medical technology and clinical practice often result in the use of more expensive services, leading to increased healthcare spending and utilization.

Legislative & regulatory changes: Premiums reflect an increase in projected average cost per member driven by adverse morbidity impacts associated with the expiration of enhanced APTCs and changes in federal premium subsidy eligibility.

WELLMARK HEALTH PLAN OF IA:

Scope and Range of Rate Increase

Wellmark Health Plan of Iowa, Inc. (Wellmark) has requested an average rate increase of 5.0% for ACA-compliant policies effective January 1, 2027. Rate increases vary by plan, ranging from -2.3% to 10.7%, and do not include rate changes due to age of the members on the policy. As of March 31st, 2026, there are approximately 80,000 individual members in the pool. Most of the members in the pool are eligible for a premium subsidy and may not experience a post-subsidy rate change within the range above.

Financial Experience of the Product

Wellmark anticipates 2026 experience will be worse than the target loss ratio. Applying the requested rate increases, Wellmark projects a loss ratio of 89% for this block of business in 2027. It should be noted that the projected Medical Loss Ratio (MLR) meets the minimum requirement of 80% defined in the ACA.

Changes in Medical Service Costs

Annual trend of 4.5% was used to project claims from the experience period into the rating period and drives rates up for 2027. This trend assumption includes changes in service costs and utilization.

Changes in Benefits

Plan design changes were made to Wellmark’s 2027 product offerings. These changes drive rates down for 2027. Rate changes provided above incorporate the impact of plan design changes.

Administrative Costs and Anticipated Profits

The main drivers of administrative expenses are employee salaries and benefits, broker and agent commissions, and various governmental taxes and fees. Wellmark strives to maintain a low administrative expense as a percent of premium, as well as the underlying cost of care, in order to provide the best value to our customers. With a decrease to the Exchange User Fee, smaller government fees in 2027 are driving rates down.

American Rescue Plan Enhanced Subsidy Expiration

The enhanced subsidies afforded in the American Rescue Plan expired in 2026. Wellmark anticipates this change will result in worse market risk, driving rates up.

Iowa

2027 Rate Changes

Medica

2027 Rate Changes - Georgia +20.7% for unsubsidized indy market enrollees

Charles Gaba — Mon, 13 Jul 2026 17:09:05 +0000

Mon, 07/13/2026 - 1:09pm

Hoo boy. they announced they were pulling out of the entire individual market nationally earlier this year. I don't know how many Georgians are enrolled in Cigna plans at the moment, but it was around 35,000 as of a spring 2025.

Peach State Health Plan (by Centene) also appears to be dropping out of the GA market, although they were always just a subsidiary of Ambetter of Peach State anyway. This gets a bit confusing since they so I'm not entirely sure what the situation is. In any event, they only had around 3,000 enrollees as of spring 2025.

One carrier is newly entering the Georgia individual market, however: Antidote Health of GA.

Beyond that, as I said, it's a pretty ugly state of affairs. In 2025, over 1.5 million Georgians signed up for ACA plans during Open Enrollment, with an average of around 1.3 million actually enrolled in coverage per month. This year, only ~1.3 million signed up to begin with, actual enrollment was below 1.2 million by February, and it had reportedly dropped to around 950,000 as of April.

The actual rate filings suggest it may be even worse than that: They only total around 920,000 people as of March/April 2026 including off-exchange enrollment...possibly breaking 950,000 if you assume that both Cigna and Peach State's enrollees were still as high as they had been a year earlier, which is unlikely.

In any event, the insurance carriers participating next year are requesting full price average rate increases ranging from 16.9% (BCBS of GA) to as high as a stunning 54.3% (UnitedHealthcare)...with a weighted average around 20.7% higher than the current premiums are.

If approved as is, this would amount to unsubsidized enrollees paying another $1,925/year apiece on in premiums alone on average on top of the massive hikes they're seeing this year.

Georgia

2027 Rate Changes

Fri, 07/10/2026 - 4:55pm
about 100,000 Virginians have lost their health coverage this year as a result of higher premiums, according to a new press release.

“Most Virginians losing Marketplace coverage this year do not have any other options for health insurance coverage,” exchange director Keven Patchett said. “The new affordability program will go a long way toward helping to ease the cost burden, allowing more Virginia families to enroll in and maintain high-quality health coverage.”

The program targets Virginia households with incomes between 138% and 250% of the federal poverty level, which represents about 45% of people in the state who have lost their coverage this year, according to state data.

While some consumers enrolled in lower-tier plans with lower premiums, others were priced out or canceled their plans after a few months. Overall, enrollment dropped by 20% compared to last summer, the state exchange reported.

The funds will be available for eligible Virginians to tap into starting November 1 through Dec. 31.

First off, the phrasing of the highlighted snippets is a bit confusing, but:

Effectuated ACA coverage was 362,514 as of June 2025 & 363,848 as of July 2025. A ~20% drop from either of those puts current effectuated enrollment at around ~290,000 people as of June/July 2026.

This is actually only a net drop of around ~72,000, not ~100,000. The discrepancy is presumably because that ~100K figure doesn't include other Virginians who weren't previously enrolled who have gained coverage this year.

In any event, assuming that the "20% drop" compares June 2026 to June 2025, here's what that looks like visually:

This also means that the monthly average VA ACA enrollment is down around 46,000 people so far this year, or ~12.7%:

As for the new state subsidies, $150 million is actually pretty generous, but it still wouldn't fully replace all of the lost federal tax credits. According to an analysis by the state itself last fall, they'd have to come up with Virginia's unsubsidized premiums have shot up over 20% this year, meaning it takes more funding to cover the gap of the lost tax credits for the same number of people than it did last year.

Regardless, this is still excellent news for the ~200,000 lower-income Virginians...assuming they can survive until January 1st, 2027, that is...
Virginia
SBMs
State-baed Exchanges
VA Insurance Marketplace
State Subsidies
- Wed, 07/08/2026 - 1:58pm
  Yesterday I noted that the Centers for Medicare & Medicaid Services (CMS) has published a new database which updates the official effectuated ACA exchange enrollment data for all 50 states (+DC) through February 2026.
  
  This means that I finally have comprehensive effectuated enrollment data for the first two months of the year for every state, as opposed to only having Open Enrollment Period (OEP) plan selections, which aren't the same thing.
  
  While there are still four months of effectuated enrollment data missing, this still fills in a lot of the missing pieces of the year over year enrollment puzzle, since this new database also includes state-level effectuations from August - December 2025 as well (previously I only had the national total for those months).
  
  In addition, there's several states which provide their own monthly enrollment reports...although those numbers don't always match up perfectly with the official CMS reprots, since there can be differences in methodology, "as of" dates and so on. I'll get more into that below.
  
  First, however, here's a table breaking out just how many Americans were enrolled in ACA exchange healthcare coverage as of February 2026 compared to one year earlier in February 2025:
  
  Nationally, effectuated enrollment has dropped by more than 2.6 million people year over year...with the vast bulk of this being found in states hosted by the federal exchange, while the state-based exchanges saw a smaller reduction (important caveat: Illinois switched from the federal exchange (HealthCare.Gov) to its own state-based exchange last fall, which skews the breakout for each category a bit; I'm counting IL as a SBE for purposes of this breakout).
  
  Update: The 2025 FFM & SBE subtotals above have been corrected.
  
  At the state level, there are 15 states which saw year over year enrollment drop by 20% or more: AL, AZ, IN, KS, LA, MI, MN, MS, MO, NE, NC, OH, OK, SC & WY. The biggest percentage drops were OHIO and OKLAHOMA, where February enrollment was more than 30% lower in 2026 than in 2025.
  
  By contrast, there's exactly one state which saw a net increase in effectuated enrollment as of February: NEW MEXICO, which accomplished this thanks to the state fully backfilling 100% of all lost federal tax credits for 100% of their enrollees. They're they only state to pull this off, although several other states are covering all or at least some of the lost subsidies for a portion of their enrollees. As a result, New Mexico's effectuated enrollment as up a whopping 14.5% as of February...although even this still shows a bit of a drop from the OEP tally (2026 OEP selections were 17% higher than they were during the 2025 OEP).
  
  While no other states were up year over year, there were several which saw drops of 5% or less as of February, including CT, DC, ID, IL, MA, PA, RI & TX. Connecticut and Massachusetts provide their own supplemental state financial subsidies, while Illinois, Pennsylvania and Texas all have robust Premium Alignment pricing policies which are helping mitigate the financial damage and limiting the enrollment losses.
  
  Here's another way of looking at the data: This table compares effectuated coverage in each state as of February against the same number in January as well as the plan selection tally during the 2026 Open Enrollment Period itself, to give an idea of how misleading that initial OEP figure was (which, again, was already ~1.2 million lower than it was during the 2025 OEP):
  
  When you look at it this way, the drop is even more stark: Nationally, effectuated enrollment had dropped over 17% from the OEP total (which, again, was already down ~1.2 million from a year prior). That's nearly 4 million fewer actually enrolled in healthcare coverage than the official OEP plan selection report indicated.
  
  At the state level, this ranges from only 3.7% lower in New Mexico to a stunning 39% drop in Mississippi. Sixteen states have seen their enrollment plummet by 20% or more apiece, five of which are down over 30% vs. the end of Open Enrollment.
  
  Unlike my "cost analysis" series which I just wrapped up yesterday, I'm not going to create 51 separate blog posts about this data; instead, I'm going to highlight a few of the more noteworthy states.
  
  First up, here's the five states which saw the sharpest decline from OEP through February 2026: OK, IN, LA, SC & MS:
  
  Next, here's the five states which have seen the smallest drop from 2026 OEP through later in the year...and again, thanks to all five of these providing their own regular effectuation reports, I have data from March or later for each of them. It's also worth noting that four of these five states provide supplemental state subsidies to some (or all in the case of New Mexico) of their ACA enrollees:
  
  California: down just 7.3% vs. the OEP total).
  
  Connecticut: down just 3.1% vs. the OEP total).
  
  Nevada: According to a Plurbius News article from May 22nd, Nevada's effectuated enrollment had dropped by 11.5% since the OEP total as of May 1st.
  
  New Mexico: down 10.2% from OEP.
  
  Vermont: According to the same Plurbius News story, Vermont's effectuated enrollment stood at 28.5K as of April, down 6.0% from the OEP tally.
  
  CMS
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  - Tue, 07/07/2026 - 12:26pm
    A year and a half ago, just one day before Donald Trump was sworn in as President for the second time, I posted the a passage from near the beginning of George Orwell's 1984:
    
    But actually, he thought as he re-adjusted the Ministry of Plenty’s figures, it was not even forgery. It was merely the substitution of one piece of nonsense for another. Most of the material that you were dealing with had no connexion with anything in the real world, not even the kind of connexion that is contained in a direct lie. Statistics were just as much a fantasy in their original version as in their rectified version. A great deal of the time you were expected to make them up out of your head.
    
    For example, the Ministry of Plenty’s forecast had estimated the output of boots for the quarter at 145 million pairs. The actual output was given as sixty-two millions. Winston, however, in rewriting the forecast, marked the figure down to fifty-seven millions, so as to allow for the usual claim that the quota had been overfulfilled. In any case, sixty-two millions was no nearer the truth than fifty-seven millions, or than 145 millions.
    
    Very likely no boots had been produced at all. Likelier still, nobody knew how many had been produced, much less cared. All one knew was that every quarter astronomical numbers of boots were produced on paper, while perhaps half the population of Oceania went barefoot. And so it was with every class of recorded fact, great or small. Everything faded away into a shadow-world in which, finally, even the date of the year had become uncertain.
    
    my early fears proved to be disturbingly accurate, as the Trump Regime began purging terrabytes of data from dozens of official federal Health & Human Services Dept. websites, including the CDC, FDA and NIH. It got so bad that I archived the entire public-facing versions of all three of these sites...and even threw in the site for the Centers for Medicare & Medicaid Services (CMS) itself for good measure.
    
    If you use public data products from the CDC or other US federal agencies Download them NOW [This is how I’m spending my Friday]
    
    From a journalist friend: Just spreading the word. The CDC is purging data, so people should archive their favorite CDC datasets today, namely ones around race/ethnic diversity, LGBTQ, and reproductive health. Also health data involving climate. The youth risk behavior survey has already gone down.
    
    Things got even worse once Elon Musk and his DOGE Hitler Youth Incel Brigade were given free rein and As I kept stating month after month:
    
    It's also noteworthy that these numbers are being officially recognized by the Musk/Trump admin under the circumstances.
    
    ...As for my concerns about potential manipulation of data by the Musk/Trump Admin, once again I'm still not seeing any obvious red flags in this month's report.
    
    Again, I'll continue to keep a close eye on this, but it doesn't look like Musk/Trump's CMS are messing with this data as of yet.
    
    I also kept posting the following postscript to the monthly Medicare reports:
    
    It's also worth noting that, given the Musk/Trump Admin's obsession with erasing any reference or data regarding gender, race or ethnicity, the Medicare enrollment reports still include breakouts of those demographic factors.
    
    Now, it's entirely possible that the Trump Regime simply hasn't gotten around to messing with this particular data, or that they've determined that doing so would be a bridge too far (hah!), but for whatever reason, so far at least, they've been publishing Medicare, Medicaid & CHIP enrollment reports on monthly basis...and, just as importantly, so far I haven't seen anything in any of the data which has raised any red flags about the books being cooked.
    
    This brings me to today's development. While CMS has regularly published official state-level (sometimes county-level) enrollment reports for Medicaid, CHIP and Medicare for years, when it comes to Affordable Care Act enrollment data, it's always been somewhat spotty.
    
    During the official Open Enrollment Period (OEP) itself, which has ran anywhere from 75 days to 197 days depending on the year (the 2026 OEP ran 107 days in most states but as long as 123 days in a few), CMS has typically published "Snapshot Reports" either once a week or once every other week which include data about how many people in every state select exchange coverage. As I've noted many times, however, that's not the same thing as the number of people with effectuated coverage.
    
    About half of the states which operate their own ACA exchanges, such as California, Colorado, Connecticut, Maryland, Massachusetts, Minnesota, New Mexico and New York typically publish monthly (or near-monthly) effectuated enrollment reports throughout the year. For most states, however, I usually have to rely on just two or three reports published by CMS:
    
    Every spring, usually in late March, they'll publish the official OEP ACA Marketplace Public Use File, which includes lots of detailed demographic data...except again, this includes everyone who selected plans during OEP, not those who have effectuated coverage, which is always somewhat smaller.
    
    Later in the year, typically sometime over the summer, they'll usually publish an "
    
    Towards the end of the year, they might (or might not) post another Public Use File which includes which appears to be identical to the monthly Medicaid/CHIP and Medicare enrollment reports, but specifically for effectuated ACA exchange enrollment!
    
    Assuming this is true, it's a genuinely good thing for data transparency which will also make my life easier...although there's one caveat which I'll address below.
    
    But first, let's take a look at the new database:
    
    The Health Insurance Exchanges Monthly Effectuated Enrollment data provide select metrics on monthly effectuated enrollment across the Federally Facilitated Exchange (FFE) and State‑Based Exchanges on the Federal Platform (SBE‑FPs), which both use the federal enrollment platform (HealthCare.gov), as well as State‑Based Exchanges (SBEs) that operate their own eligibility and enrollment platforms.
    
    These metrics include effectuated enrollment counts by state, exchange platform type, year and month.
    
    Resources for Using and Understanding the Data
    
    The data are gathered from the Centers for Medicare and Medicaid Services Enrollment and Payment System (EPS), which serves as a central repository for capturing, organizing, aggregating, and analyzing payment data for the FFE, SBE-FP and SBE Exchanges. Effectuated enrollment data reflect the date of retrieval from the EPS. Please see the Methodology for more information on posting schedule and data availability.
    
    Sure enough, when I download the actual data set, it provides effectuated ACA exchange enrollment for all 50 states (+DC) for every month from every year starting in 2016...all the way up through February 2026.
    
    Unfortunately, it still doesn't include this data for the first two years that the ACA exchanges were operating (2014 & 2015), but this is still an extremely valuable resource which helps fill in some of the gaps in my existing data, and which will prove highly useful going forward assuming they do in fact update it on a monthly basis (also assuming, of course, that the data is accurate).
    
    Until now, I was missing both national and state-level effectuation data from August 2025 onward, as well as national data for January 2026. I have state level data for the states which publish their own monthly reports, but nothing for most states.
    
    This new database fills in both national and state-level data for August 2025 - February 2026...while also making modifications to the monthly data from 2025.
    
    I'll get into the state-level data in future posts, but for now, here's what it looks like at the national level:
    
    Here's where things may get a little confusing, as there's three different ways of measuring effectuated enrollment:
    
    OEP QHPs: The total number of people who selected ACA exchange healthcare policies during the annual Open Enrollment Period
    
    Monthly Effectuated Enrollees: The number of people enrolled in effectuated (ie, in effect) coverage for that specific month
    
    Average: The monthly average number enrolled in effectuated coverage for every month to date.
    
    This is why, for instance, the headline in my own piece about last weeks ASPE report noting that effectuated enrollment had dropped to ~19.2 million nationally referred to a year over year drop of 2.6 million people, while over at NOTUS,
    You can also see the trend line starting to form already by looking at the last column:
    
    OEP plan selections dropped by 4.8% from OEP 2025 to OEP 2026 (down ~1.2M)
    
    Effectuated enrollment as of January 2026 was nearly double that rate: Down 9.1% compared to January 2025 (down ~2.0M)
    
    Effectuated enrollment as of February 2026 was down by even more: 12.0% compared to February 2025 (down ~2.6M)
    
    Based on the more recent enrollment data I've seen from 15 states so far, I'm pretty certain that the downward trend has only continued nationally as more and more enrollees have been unable to keep up with the 58% higher (on average) premiums.
    
    Here's what this looks like visually, updated to include the official national CMS data for August 2025 - February 2026 (I'm not including 2014 - 2018 as that makes the graph too cluttered).
    
    As you can see, I've included projections for the remaining 10 months of the year assuming that it follos the same pattern as 2025 or the same pattern as 2019. If it follows the 2025 pattern going forward, around 2.6 million fewer people will be enrolled on average for the full year...roughly the same as where things stand today.
    
    If, however, it follows the 2019 pattern (I use 2019 because that was the last pre-COVID year), then effectuated enrollment will continue to drop off and will end up at around ~18.1 million by December...which would mean nearly 4.0 million fewer people enrolled each month on average.
    
    Unfortunately, I strongly suspect that even this is an optimistic scenario, and that the actual pattern will be an even sharper drop-off. We could be looking at as many as 6 million Americans losing ACA healthcare coverage on average in calendar year 2026.
    
    That brings me to the caveat I mentioned earlier...the modifications to 2025 effectuated enrollment data included in the new database numbers.
    
    Here's a side by side comparison of the national monthly effectuated enrollment data according to three different official CMS public use files:
    
    (published November 2025; data thru July 2025)
    
    As you can see, the effectuated total was lower for each month according to the November report than it was in the July report...and today's new database has the numbers dropping even further yet.
    
    While it's understandable to be concerned that the Trump Regime playing with the numbers, this does pass the smell test for me, for three reasons. First, each month.
    
    In addition, I went back and checked the years prior to 2025 and the new ACA effectuated enrollment database doesn't make a single change to any of those--the numbers for every month are identical.
    
    The final reason I'm pretty confident that this data is legitimate (at least so far) is that while the drop may look significant (July 2025 is over 200,000 lower in the new database than it was in the November spreadsheet), it's actually close to a rounding error for most months, ranging from 0.23% to 0.95% lower depending on the month.
    
    Anyway, I'll be keeping a close eye on the data in this new resource and will note if it seems to be out of line with what I'd expect (as well as other data sources such as the ~20 state-based exchanges themselves), but for the moment, I welcome this development.
    
    CMS
    ACA
    Effectuated Enrollment
    Medicaid
    CHIP
    Medicare
    Effectuation Report
    Mon, 07/06/2026 - 9:50am
    REMINDER: Use the drop-down menu above to find the analysis for your state.
    
    IMPORTANT: See the original post in this series for an explanation of the methodology.
    
    Regular readers know that I've been obsessing over the massive increases in both gross as well as net premiums for ACA health insurance policy enrollees being caused by the combination of Congressional Republicans allowing the enhanced federal tax credits to expire as well as other Trump Regime policy changes for well over a year and a half now.
    
    I've written countless analyses of how much both gross and net premiums skyrocketed from 2025 to 2026 across different states, different income levels and various other demographics...and recently it was confirmed that over 2.6 million ACA exchange enrollees had already been priced out of the market as of February, with the number almost certain to climb further throughout the rest of 2026.
    
    As I've repeatedly warned, however, the increases in premium costs (whether gross or net) are only half the story. The other big shoe which is dropping this year is increased out of pocket costs as millions of the ~19.2 million or so remaining enrollees as of February have been forced to downgrade their coverage to avoid (or at least minimize) those massive premium spikes.
    
    In most cases this means moving to plans with higher deductibles, higher co-pays & higher coinsurance costs. In many cases this has also included moving to plana with worse networks, referral requirements to see specialists and so on.
    
    With that in mind, that's exactly what I've decided to set out to do: Calculate the average year over year increase not just in net premiums (that is, how much more ACA enrollees are having to pay each month) but also the year over year change in average out of pocket costs.
    
    After 51 state-by-state analyses (including DC), I've finally reached the end of this project. Let's look at the NATIONAL data:
    
    Here's national ACA exchange plan selections during Open Enrollment by household income level this year vs. last. It's important to keep in mind that this data is as of the end of the 2025 & 2026 Open Enrollment Periods only; it does not reflect actual effectuated enrollment for either year, which was ~21.8 million as of February 2025 and 19.2 million as of February 2026:
    
    As you can see, OEP plan selections dropped substantially year over year across nearly every income bracket...and by as much as ~44% for enrollees who earn less than 100% of the Federal Poverty Level (FPL) and those who earn 400 - 500% FPL. The reasons for each of these are similar, though for different reasons:
    
    Enrollment below the poverty line plummeted largely because the Trump Regime eliminated subsidy eligibility for hundreds of thousands of low income documented (ie, legally residing) immigrants who have lived in the United States for less than 5 years and thus aren't eligible for Medicaid.
    
    Enrollment above 4x the poverty line plummeted largely because Congressional Republicans pointedly refused to extend the improved subsidies which allowed this population to be eligible for financial assistance on a sliding scale.
    
    Both populations now have to pay full price, which is utterly impossible for the former and often impossible for the latter (especially if they're 50 or older).
    
    Onto the main analysis:
    
    Here's total Open Enrollment plan selections for both 2025 & 2026 broken out by Actuarial Value (AV) category.
    
    The first table is based on official metal level tiers, but it's the second table which is critical, since a huge chunk of ACA enrollees are usually enrolled in CSR Silver plans (which include Cost Sharing Reduction assistance). CSR assistance dramatically boosts the AV of Silver plans up to Platinum levels in most cases.
    
    As I've noted for most of the individual states, millions of ACA enrollees were forced to downgrade to worse plans this year in order to at least partially mitigate the premium hikes. Enrollment in high-value CSR and Platinum plans dropped by 7.4 - 32%, as did lower-value Silver plan enorllment...while low-value Bronze and Catastrophic plan enrollment jumped by 25% or higher. The saving grace is that Gold plan enrollment also jumped by 24%, thanks primarily to a dozen or so states implementing robust Premium Alignment pricing.
    
    Overall, however, the average actuarial value for enrollees still dropped by 3.4 points overall:
    
    By combining these numbers with the average gross premiums per enrollee I'm able to calculate an estimate of the average total medical expenses each enrollee racks up each year assuming an 80% average Medical Loss Ratio (as I stated in the original post, this can vary widely by carrier and year, so should be considered a very broad average only), which looks like the table below.
    
    Important: Neither the table nor the graph below include the impact in either year of STATE-BASED FINANCIAL SUBSIDIES, which range from modest to very generous across a dozen or so states. I've accounted for those state subsidies in the individual analyses of most of those which are offering them this year.
    
    Nationally, on average, net ACA premiums have jumped by 58% this year vs. last, from $113/month to $178/month, or around $780/year more per enrollee.
    
    Meanwhile, by my estimates, average out of pocket expenses have jumped by around 46%, or another $716/year apiece.
    
    Combined, to the best of my calculations, the ~19.2 million Americans who managed to hold onto their coverage through February of this year are paying over 50% more in total healthcare costs...or a whopping ~$1,500 apiece on average.
    
    Here's what all 50 states (+DC) look like side by side, sorted lowest to highest by average net 2026 premiums. Note that, again, this graph does not include the additional subsidies available to some or all enrollees in 9 states this year. I've noted those 9 states as well as highlighting the 4 states which have Basic Health Plan (BHP) programs for residents who earn up to 200% FPL; BHP programs severely skew average net premiums for the enrollees who earn more than 200% FPL since the ACA exchange subsidies for that population are far less generous.
    
    The next graph lines up every state by estimated average per enrollee out of pocket expenses this year versus last. Note that the order is different from the net premium graph above.
    
    Whew! And with that, I'm done!
    
    2026 Open Enrollment
    MOOP
    Deductibles
    APTC
    eAPTC
    Actuarial Value
    Thu, 07/02/2026 - 1:07pm
    IMPORTANT: See the original post in this series for an explanation of the methodology.
    
    Regular readers know that I've been obsessing over the massive increases in both gross as well as net premiums for ACA health insurance policy enrollees being caused by the combination of Congressional Republicans allowing the enhanced federal tax credits to expire as well as other Trump Regime policy changes for well over a year and a half now.
    
    I've written countless analyses of how much both gross and net premiums skyrocketed from 2025 to 2026 across different states, different income levels and various other demographics...and recently it was confirmed that over 2.6 million ACA exchange enrollees had already been priced out of the market as of February, with the number almost certain to climb further throughout the rest of 2026.
    
    As I've repeatedly warned, however, the increases in premium costs (whether gross or net) are only half the story. The other big shoe which is dropping this year is increased out of pocket costs as millions of the ~19.2 million or so remaining enrollees as of February have been forced to downgrade their coverage to avoid (or at least minimize) those massive premium spikes.
    
    In most cases this means moving to plans with higher deductibles, higher co-pays & higher coinsurance costs. In many cases this has also included moving to plana with worse networks, referral requirements to see specialists and so on.
    
    With that in mind, that's exactly what I've decided to set out to do: Calculate the average year over year increase not just in net premiums (that is, how much more ACA enrollees are having to pay each month) but also the year over year change in average out of pocket costs.
    
    Let's look at NEW MEXICO:
    
    Here's a look at ACA exchange plan selections during Open Enrollment by household income level this year vs. last.
    
    It's vitally important to understand that New Mexico is truly unique: While some states have either established or beefed up their own supplemental state subsidy programs for ACA enrollees as a response to the expiration of the enhanced federal tax credits, New Mexico is the only one which is fully backfilling 100% of the lost subsidies for 100% of all ACA enrollees who were eligible for them last year.
    
    When I say all enrollees, I'm not just talking about those who earn 100 - 400% FPL; I'm also talking about enrollees who earn more than 400% FPL as well as eligible enrollees who earn less than 100% FPL (all of the former and most of the latter had their federal subsidy eligibility cut off by the Trump Regime starting January 1st).
    
    Even more impressive: New Mexico is doing this in addition to their
    
    And finally, all of the above is in addition to the state also having a robust Premium Alignment pricing policy!
    
    As a result of all of this, New Mexico is one of a handful of states which has seen their enrollment increase year over year...and is the only state to seen it increase by double digits! Plan selections during Open Enrollment actually jumped by as much as 33% in some income brackets, although it did drop somewhat over the 400% FPL threshold.
    
    Overall, OEP plan selections increased by 18.1% year over year, from ~70,000 during OEP 2025 to more than 83,000 this year, although effectuated enrollment was
    
    Onto the main analysis:
    
    Here's total Open Enrollment plan selections for both 2025 & 2026 broken out by Actuarial Value (AV) category. It's important to note that unlike other states where I have plans broken out by the more traditional metal levels & CSR tiers, due to New Mexico's unique Turquoise Plan arrangement, I have them broken out a bit differently.
    
    Usually, the categories are: Catastrophic, Bronze, Silver (standard), Silver CSR 73, Gold, Silver CSR 87, Platinum, Silver CSR 94 ranging from 55% - 94% AV.
    
    However, New Mexico didn't offer Catastrophic plans or official Platinum plans either year, and they've baked their state subsidies into the other plans, so they have Bronze, Expanded Bronze, Silver (base), Gold (base) Gold T3, Silver T2 and Silver T1, ranging from 60 - 99% AV.
    
    With that in mind, here's how that breaks out year over year...and thanks to the combination of Premium Alignment, Turquioise Care and fully backfilled premium tax credits, the average Actuarial Value for New Mexico enrollees has actually increased this year, from 87.8% to 89.8%!
    
    By combining these numbers with the average gross premiums per enrollee I'm able to calculate an estimate of the average total medical expenses each enrollee racks up each year assuming an 80% average Medical Loss Ratio (as I stated in the original post, this can vary widely by carrier and year, so should be considered a very broad average only), which looks like the table below.
    
    IMPORTANT: The average per enrollee state subsidies for both premiums and CSR assistance below are rough and are based on this
    
    Assuming I have my estimates correct, the impact is stark: Without the state stepping up, average net premiums would have nearly doubled year over year...but thanks to them, net premiums only went up 6.5% overall. Similarly, thanks to the state stepping up with Turquoise Care, by my very rough estimates, average out of pocket expenses have only increased by around 3.8%.
    
    Combined, to the best of my calculations, New Mexicans are only paying around $135 more apiece this year than last on average...when it would have been more like $1,900 each otherwise.
    
    Next up: NEW YORK.
    
    2026 Open Enrollment
    MOOP
    Deductibles
    APTC
    eAPTC
    Actuarial Value
    New Mexico
    Thu, 07/02/2026 - 12:49pm
    IMPORTANT: See the original post in this series for an explanation of the methodology.
    
    Regular readers know that I've been obsessing over the massive increases in both gross as well as net premiums for ACA health insurance policy enrollees being caused by the combination of Congressional Republicans allowing the enhanced federal tax credits to expire as well as other Trump Regime policy changes for well over a year and a half now.
    
    I've written countless analyses of how much both gross and net premiums skyrocketed from 2025 to 2026 across different states, different income levels and various other demographics...and recently it was confirmed that over 2.6 million ACA exchange enrollees had already been priced out of the market as of February, with the number almost certain to climb further throughout the rest of 2026.
    
    As I've repeatedly warned, however, the increases in premium costs (whether gross or net) are only half the story. The other big shoe which is dropping this year is increased out of pocket costs as millions of the ~19.2 million or so remaining enrollees as of February have been forced to downgrade their coverage to avoid (or at least minimize) those massive premium spikes.
    
    In most cases this means moving to plans with higher deductibles, higher co-pays & higher coinsurance costs. In many cases this has also included moving to plana with worse networks, referral requirements to see specialists and so on.
    
    With that in mind, that's exactly what I've decided to set out to do: Calculate the average year over year increase not just in net premiums (that is, how much more ACA enrollees are having to pay each month) but also the year over year change in average out of pocket costs.
    
    Let's look at WYOMING:
    
    Here's a look at ACA exchange plan selections during Open Enrollment by household income level this year vs. last.
    
    Like most states, Wyoming has seen enrollment plummet across most income brackets. Overall, plan selections have dropped by 5,000 people versus OEP 2025...which is a tiny number in the scheme of things but which represents an 11% year over year reduction:
    
    Onto the main analysis:
    
    Here's total Open Enrollment plan selections for both 2025 & 2026 broken out by Actuarial Value (AV) category. The first table is based on official metal level tiers, but it's the second table which is critical, since a huge chunk of ACA enrollees are usually enrolled in CSR Silver plans (which include Cost Sharing Reduction assistance). CSR assistance dramatically boosts the AV of Silver plans up to Platinum levels in most cases.
    
    As has happened in nearly every other state, the remaining ~40,000 Wyomingites who were able to sign up for coverage have been forced to "buy down" to worse coverage; enrollment in all of the high-value metal levels & AV categories is down, while enrollment in standard Silver and Bronze plans has jumped significantly (granted, "significantly" is a relative term given Wyoming's tiiny population).
    
    As a result, the average actuarial value for enrollees dropped by 3 points.
    
    By combining these numbers with the average gross premiums per enrollee I'm able to calculate an estimate of the average total medical expenses each enrollee racks up each year assuming an 80% average Medical Loss Ratio (as I stated in the original post, this can vary widely by carrier and year, so should be considered a very broad average only), which looks like so:
    
    On average, Wyoming enrollees, who already pay among the highest gross premiums in the country, have seen their net premiums jump by 75% this year, while by my estimates they're also paying around 43% more in out of pocket expenses.
    
    Combined, that's roughly a 55% average increase in total healthcare expenses on average...or a stunning $2,300 per enrollee.
    
    Oh yeah...based on deductibles have also gone up ~45% this year and now average around $3,400 for single coverage. The maximum (theoretical) out of pocket cut-off for all ACA enrollees went up by over 15% this year as well, however, to $10,600 for single coverage.
    
    Next up: NATIONAL AVERAGE!
    
    2026 Open Enrollment
    MOOP
    Deductibles
    APTC
    eAPTC
    Actuarial Value
    Wyoming
    Thu, 07/02/2026 - 12:48pm
    IMPORTANT: See the original post in this series for an explanation of the methodology.
    
    Regular readers know that I've been obsessing over the massive increases in both gross as well as net premiums for ACA health insurance policy enrollees being caused by the combination of Congressional Republicans allowing the enhanced federal tax credits to expire as well as other Trump Regime policy changes for well over a year and a half now.
    
    I've written countless analyses of how much both gross and net premiums skyrocketed from 2025 to 2026 across different states, different income levels and various other demographics...and recently it was confirmed that over 2.6 million ACA exchange enrollees had already been priced out of the market as of February, with the number almost certain to climb further throughout the rest of 2026.
    
    As I've repeatedly warned, however, the increases in premium costs (whether gross or net) are only half the story. The other big shoe which is dropping this year is increased out of pocket costs as millions of the ~19.2 million or so remaining enrollees as of February have been forced to downgrade their coverage to avoid (or at least minimize) those massive premium spikes.
    
    In most cases this means moving to plans with higher deductibles, higher co-pays & higher coinsurance costs. In many cases this has also included moving to plana with worse networks, referral requirements to see specialists and so on.
    
    With that in mind, that's exactly what I've decided to set out to do: Calculate the average year over year increase not just in net premiums (that is, how much more ACA enrollees are having to pay each month) but also the year over year change in average out of pocket costs.
    
    Let's look at WISCONSIN:
    
    Here's a look at ACA exchange plan selections during Open Enrollment by household income level this year vs. last.
    
    Like most states, Wisconsin has seen enrollment plummet across nearly every income bracket, especially among enrollees who earn less than 100% of the Federal Poverty Level (FPL), which is due to the Trump Regime eliminating subsidy eligibility for around 1.4 million low-income legally residing non-citizens...and those who earn more than 400% FPL, since they're also no longer eligible for any financial assistance thanks to Republicans allowing the improved subsidies to expire.
    
    The only income bracket which saw a year over year increase is the 300 - 400% FPL range, and I'm pretty sure much of that is due to households who usually earn slightly more than 400% FPL estimating their 2026 annual income at ~390% FPL who are now scrambling to ensure that their actual 2026 income doesn't inch over the cut-off threshold.
    
    Overall, plan selections have still dropped by 7.1%, or over 22,000 people versus OEP 2025...and since then, effectuated enrollment has almost certainly dropped even further.
    
    Onto the main analysis:
    
    Here's total Open Enrollment plan selections for both 2025 & 2026 broken out by Actuarial Value (AV) category. The first table is based on official metal level tiers, but it's the second table which is critical, since a huge chunk of ACA enrollees are usually enrolled in CSR Silver plans (which include Cost Sharing Reduction assistance). CSR assistance dramatically boosts the AV of Silver plans up to Platinum levels in most cases.
    
    As shown below, most of the ~290,000 Wisconsinites who did select policies during Open Enrollment had to "buy down" to a worse plan to mitigate the damage.
    
    As a result, the average actuarial value for enrollees dropped 2.6 points, from 73.6% to 71.0%:
    
    By combining these numbers with the average gross premiums per enrollee I'm able to calculate an estimate of the average total medical expenses each enrollee racks up each year assuming an 80% average Medical Loss Ratio (as I stated in the original post, this can vary widely by carrier and year, so should be considered a very broad average only), which looks like so:
    
    Average net premiums jumped by a whopping 50% on average...while, by my estimates, average out of pocket spending went up around 30% as well this year. Combined, that's an average net healthcare cost hike of ~39%, or around $1,700 per enrollee.
    
    Interestingly, based on
    
    Next up: WYOMING.
    
    2026 Open Enrollment
    MOOP
    Deductibles
    APTC
    eAPTC
    Actuarial Value
    Wisconsin
    Thu, 07/02/2026 - 12:48pm
    IMPORTANT: See the original post in this series for an explanation of the methodology.
    
    Regular readers know that I've been obsessing over the massive increases in both gross as well as net premiums for ACA health insurance policy enrollees being caused by the combination of Congressional Republicans allowing the enhanced federal tax credits to expire as well as other Trump Regime policy changes for well over a year and a half now.
    
    I've written countless analyses of how much both gross and net premiums skyrocketed from 2025 to 2026 across different states, different income levels and various other demographics...and recently it was confirmed that over 2.6 million ACA exchange enrollees had already been priced out of the market as of February, with the number almost certain to climb further throughout the rest of 2026.
    
    As I've repeatedly warned, however, the increases in premium costs (whether gross or net) are only half the story. The other big shoe which is dropping this year is increased out of pocket costs as millions of the ~19.2 million or so remaining enrollees as of February have been forced to downgrade their coverage to avoid (or at least minimize) those massive premium spikes.
    
    In most cases this means moving to plans with higher deductibles, higher co-pays & higher coinsurance costs. In many cases this has also included moving to plana with worse networks, referral requirements to see specialists and so on.
    
    With that in mind, that's exactly what I've decided to set out to do: Calculate the average year over year increase not just in net premiums (that is, how much more ACA enrollees are having to pay each month) but also the year over year change in average out of pocket costs.
    
    Let's look at WEST VIRGINIA.
    
    Here's a look at ACA exchange plan selections during Open Enrollment by household income level this year vs. last.
    
    Like most states, West Virginia has seen enrollment plummet across most income brackets, especially among those earning more than 400% of the Federal Poverty Level. This is completely understandable given that WV has by far the most expensive unsubsidized ACA premiums in the country at over $1,300 per person on average.
    
    Overall, plan selections during Open Enrollment dropped by 16.7%, or over 11,000 people versus OEP 2025...and since then, effectuated enrollment has almost certainly dropped further yet.
    
    Onto the main analysis:
    
    Here's total Open Enrollment plan selections for both 2025 & 2026 broken out by Actuarial Value (AV) category. The first table is based on official metal level tiers, but it's the second table which is critical, since a huge chunk of ACA enrollees are usually enrolled in CSR Silver plans (which include Cost Sharing Reduction assistance). CSR assistance dramatically boosts the AV of Silver plans up to Platinum levels in most cases.
    
    As shown below, while many of the ~55,000 West Virginians who managed to survive the Open Enrollment Period did "buy down" to a worse plan, the actual net impact on average actuarial values actually didn't go down by that much: It dropped by just 1.4 points.
    
    By combining these numbers with the average gross premiums per enrollee I'm able to calculate an estimate of the average total medical expenses each enrollee racks up each year assuming an 80% average Medical Loss Ratio (as I stated in the original post, this can vary widely by carrier and year, so should be considered a very broad average only), which looks like so:
    
    On average, net premiums more than doubled from $101/mo to $208/mo. In addition, by my estimates, average out of pocket spending shot up around 21% as well this year, resulting in a combined average 43% increase in total net healthcare spending...which amounts to around $2,000 more per year per enrollee.
    
    Interestingly, based on
    
    Next up: WISCONSIN.
    
    2026 Open Enrollment
    MOOP
    Deductibles
    APTC
    eAPTC
    Actuarial Value
    West Virginia