New data show a smaller, higher-risk ACA individual market emerging after enhanced premium tax credits expired.
In Wakely’s new white paper, 2026 Individual Market Risk Pool Considerations: Emerging Data on Marketplace Post Expiration of Enhanced Subsidies, early 2026 data indicate that Affordable Care Act (ACA) individual market enrollment declined 12.0% while normalized relative risk increased 6.3% compared with the same period in 2025. The findings suggest that healthier members may be leaving the market as enhanced premium tax credits expire and premiums rise, potentially increasing underlying claim costs and creating new considerations for 2027 rate development.
Download the full white paper for details on changes to ACA enrollment, morbidity estimates, claimant ratio, and saturation of HCCs—plus the methodology, implications, and limitations behind the analysis.
DOWNLOAD NOWKey Findings at a Glance
- 12.0% decrease in enrollment from January through April 2025 to the same period in 2026.
- 6.3% increase in normalized relative risk, suggesting a higher-risk ACA individual market population.
- 0.2% increase in claimant ratios, indicating that the share of enrollees with claims remained relatively stable.
- 0.6% increase in enrollees with at least one hierarchical condition category (HCC).
- 19% to 23% estimated average full-year enrollment loss, although substantial uncertainty remains.
How Has the 2026 ACA Individual Market Risk Pool Changed?
The emerging data point to a smaller and potentially less healthy risk pool. Enrollment fell 12.0% while normalized relative risk rose 6.3%. Although early-year data are incomplete and subject to claims and coding lag, the increase in relative risk was consistent across January through April 2026 and followed an elevated pattern already observed in 2025.
Normalized relative risk is an adjusted measure of the expected health risk of the enrolled population. In this analysis, the plan liability risk score is adjusted for actuarial value and average rating factor so that changes in plan mix can be separated, in part, from changes in population risk.
What Happened to Marketplace Enrollment After Enhanced Subsidies Expired?
The expiration of enhanced premium tax credits, changes to premium tax credit eligibility, and substantial 2026 premium increases created new affordability pressures. Through April, enrollment was 12.0% lower than in the comparable 2025 period. Because 2025 enrollment remained generally stable after April while additional attrition is expected in 2026, the full-year decline could be larger.
Enrollment changes also varied materially by state and Marketplace structure. Federally Facilitated Marketplace states that expanded Medicaid experienced the largest cohort-level decline, and shifts from silver coverage toward bronze and gold plans indicate that many consumers are selecting lower-premium options with different cost-sharing exposure.
Are ACA Marketplace Enrollees Becoming Higher Risk?
The early data suggests worsening morbidity, but the relationship of normalized relative risk to morbidity is not one-to-one. Normalized relative risk increased 6.3%, and the percentage of enrollees with at least one HCC increased 0.6%. At the same time, claimant ratios—the percentage of enrollees with claims—increased only 0.2%. This pattern may indicate that the proportion of enrollees using services has changed little while the relative health risk or severity of those with documented conditions has increased.
An HHS-HCC risk score uses demographic and diagnosis information to estimate relative healthcare risk under the federal ACA risk adjustment model. Morbidity refers to the health status and expected healthcare needs of a population.
What Could These Findings Mean for 2027 ACA Premiums?
Higher normalized relative risk may translate into higher underlying claim costs, but the pricing impact will differ by state and issuer. The emerging measure reflects both changes in who remains enrolled and changes in the health status or utilization of continuing members. Issuers and regulators should compare actual 2026 enrollment, morbidity, utilization, coding, competitive positioning, and metal-level shifts with assumptions used in 2026 pricing and 2027 rate filings.
The data do not support a single market-wide premium conclusion. Carrier profitability and future rate needs will depend on how emerging experience develops, including claim cost trend, risk score completion, member churn, plan mix, and state-specific market dynamics.
How Much Could Individual Market Enrollment Decline in 2026?
Based on the first four months of experience, Wakely now estimates that average 2026 individual market enrollment could decline approximately 19% to 23% from 2025. The estimate remains uncertain because consumer responses to higher premiums, non-payment, operational actions, and state-specific market conditions will continue to affect enrollment throughout the year.
What Should Healthcare Leaders Watch Next?
Health Plans and Issuers
Monitor enrollment attrition, morbidity, utilization, coding completion, member churn, and metal-level profitability by state and issuer. Reconcile emerging experience with pricing assumptions and preserve flexibility as 2027 rates develop.
State Marketplace and Policy Leaders
Track effectuation, net attrition, plan selection shifts, affordability, and regional differences. Outreach, enrollment operations, state affordability programs, reinsurance, and Marketplace design may influence outcomes.
Actuaries and Rate-Setting Teams
Evaluate morbidity alongside claim cost trend, risk score duration, coding patterns, actuarial value, rating factors, geography, premium slopes, and issuer-level mix. Early risk scores should not be treated as a direct proxy for final claim costs.
Healthcare Policy and Strategy Leaders
Consider how affordability changes may affect coverage, plan generosity, consumer behavior, and market stability. National averages are useful, but state- and issuer-specific conditions will determine the practical impact.
About the Analysis
The analysis uses January through April 2025 and 2026 data from the Wakely National Risk Adjustment Reporting project. The dataset includes summarized information from more than 80 carriers in 37 states and represents nearly 80% of ACA-compliant individual market enrollment. Data submission is voluntary, and the information was reviewed for reasonableness but not audited.
The analysis compares enrollment, metal-level distribution, normalized relative risk, claimant ratios, and HCC prevalence across SBMs, FFM Medicaid expansion states, and FFM non-expansion states. All years were evaluated using the 2025 federal risk adjustment model.
Important Limitations
- The findings reflect only the first four months of 2025 and 2026 and may change as claims and risk scores mature.
- Risk scores are an imperfect proxy for morbidity and claim costs and are affected by coding, documentation, claims volume, member engagement, and data integrity.
- The analysis does not normalize for coding trend or all changes in geographic and membership mix.
- Issuer participation is voluntary, so the data do not represent every carrier or market.
- Results vary significantly by state, issuer, metal level, premium positioning, and Marketplace operations.
Download the white paper to understand what the emerging 2026 data could mean for ACA individual market strategy, pricing, and market stability.
