At least five health insurers have announced plans to leave the ACA Marketplace after 2026, affecting more than 600,000 enrollees across multiple states. The exits are raising new questions about the stability of the individual market and whether additional insurers could follow.

Although insurer participation in the ACA Marketplace has fluctuated for years, the latest withdrawals come at a time of growing uncertainty driven by higher premiums, declining enrollment, and federal rule changes that could further reshape the market in 2027.

Declining Marketplace enrollment drives carrier decisions

Marketplace enrollment declined in 2026, after five years of steady growth ^{– and according to a Wakely analysis, effectuated enrollment is projected to be 17% to 26% lower in 2026 than it was in 2025.}

Although we don’t yet have official nationwide 2026 effectuated enrollment data from Centers for Medicare & Medicaid Services (CMS), NOTUS (News of the United States) has obtained internal CMS documents and reported that 21% of HealthCare.gov enrollees were disenrolled in the early months of 2026 for failure to pay premiums. Across state-run Marketplaces, the drop-off was much smaller, at about 8%, due in part to the supplemental subsidies offered by some state-run Marketplaces.

But nationwide, about 17% of the people who selected a plan during the open enrollment period for 2026 (or whose coverage was automatically renewed) have already lost their coverage for failure to pay premiums.

And some state-run Marketplaces are showing significant declines in effectuated enrollment in early 2026. For example, Georgia’s effectuated Marketplace enrollment dropped from nearly 1.5 million in early 2025 ^{to 950,000 by April 2026. In Washington state (which does offer state-funded subsidies), effectuated enrollment as of February 2026 was down more than 15% from where it had been a year earlier.}

Overall, CMS projects that average effectuated Marketplace enrollment will be about 18.9 million people in 2026, ^{although it could potentially drop to as low as 16.5 million. In comparison, average effectuated Marketplace enrollment was 22.3 million people in 2025.}

A major reason for the enrollment decline is the expiration of enhanced federal subsidies at the end of 2025. Many Marketplace consumers saw premiums rise sharply when those subsidy enhancements expired. Even though millions of people switched to plans with higher out-of-pocket costs or dropped their coverage altogether, average net premiums in the Marketplace still rose by 58% in 2026.

That sharp increase in net premiums is the primary reason so many people failed to pay their premiums in the early part of 2026. ^{That matters because healthier consumers are generally more likely to drop coverage when premiums increase, while people with ongoing medical needs are more likely to keep their insurance.}

As healthier people leave the market, insurers are left covering a smaller but less healthy risk pool. That increases average medical costs per enrollee and puts upward pressure on premiums.

The Trump administration’s rule changes for 2027 could intensify those pressures even further. Federal regulators have projected that the new rules could lead to as many as 2 million additional people leaving the Marketplace.

CMS has also acknowledged that healthier enrollees may be more likely to lose or discontinue coverage under the new rules, potentially contributing to additional premium increases (although CMS notes that these premium increases may be offset by more eligibility verification for special enrollment periods and lower exchange user fees).

Marketplace participation is ultimately a business decision

For insurers, participation in the Marketplace is fundamentally a financial calculation.

Insurers continuously evaluate whether Marketplace coverage is profitable and whether the market appears stable enough to justify continued participation. When enrollment declines, risk pools worsen, and policy uncertainty increases, some insurers decide the business risk is no longer worthwhile.

There can also be state-specific policy factors involved. New Mexico, for example, requires Medicaid managed care insurers to also offer statewide Marketplace coverage. ^{But in most states, Marketplace participation decisions are largely driven by insurers’ assessment of profitability and overall market stability.}

Current withdrawals reflect a familiar cycle

Insurer participation in the Marketplaces has been cyclical over time, generally increasing when the individual market was healthier and larger, and decreasing when it was sicker and smaller. We can see a clear illustration of this when we look at how Aetna’s Marketplace participation has shifted in response to changing market conditions.

At the end of 2016, Aetna exited the Marketplace in 11 of the 15 states where it offered coverage. ^{The company then fully exited the ACA exchanges after 2017.}

But Aetna later returned to the Marketplace in 2022 and expanded into additional states in 2023. ^{However, the company once again fully exited the Marketplace after 2025.}

That pattern mirrors broader Marketplace trends over the past decade.

Insurer participation declined significantly in 2017 and 2018 amid repeated congressional repeal efforts and policy uncertainty surrounding the ACA.

Participation later rebounded during the Biden administration, when enhanced subsidies and other policy changes (including a low-income special enrollment period, fixing the “family glitch,” and Marketplace access for DACA recipients) made Marketplace coverage more affordable and accessible, resulting in far more people with Marketplace coverage.

But the number of insurers participating in the Marketplace declined again for 2026, after several of the Biden-era changes were eliminated. This was the first overall decline in insurer participation since 2018.

Still, today’s Marketplace participation levels remain significantly stronger than they were during the market instability of 2017 and 2018.

In 2018, more than a quarter of Marketplace enrollees only had access to plans from a single insurer. ^{By contrast, despite the recent decline in participation, only 1% of HealthCare.gov enrollees in 2026 had access to just one insurer’s plans.}