ACA Marketplace Insurer Participation Declines for 2026

The average number of insurers offering plans in ACA Marketplaces declined from 9.6 per state in 2025 to 9.0 in 2026, according to KFF data. This drop follows the expiration of enhanced premium tax credits at the end of 2025 and the nationwide departure of CVS Aetna from 17 states.

This trend marks the first time since 2018 that average insurer participation has fallen. While the 2026 numbers are lower than the record highs seen after enhanced tax credits were introduced in 2021, participation remains higher than it was before those credits existed.

Why is insurer participation decreasing in the ACA Marketplaces?

The primary drivers are the expiration of enhanced premium tax credits and the exit of CVS Aetna from 17 states. KFF reports that these factors contributed to the first national decline in participation since 2018.

Historically, the Marketplaces saw similar drops in 2017 when UnitedHealthcare exited most states, and again in 2018. Those earlier declines followed congressional attempts to repeal the ACA and changes to cost-sharing reduction payments and individual mandate enforcement.

Did You Know? In 2024, CVS and Centene Corporation were among the largest players in the individual market, with 8% and 18% of enrollees respectively.

Which states and counties are seeing the biggest impact?

Eighteen states experienced a net decrease in the number of issuers offering plans. Illinois and Michigan saw the sharpest declines, each losing three insurers compared to 2025 levels.

Four states—Alabama, Iowa, Louisiana, and Washington—saw a net increase of one insurer. For instance, Oscar Health entered the Alabama Exchange, and Elevance Health began offering plans in Washington.

At the local level, three in 10 counties have fewer participating insurers than last year. The number of counties with only one insurer offering plans rose to 165 in 2026, up from 93 counties in 2025.

How are major insurance companies shifting their footprints?

Insurers are frequently adjusting their coverage areas. UnitedHealth expanded its Oklahoma footprint to 74% of counties, up from 18% in 2025, but scaled back significantly in Kansas (from 87% to 33%) and South Carolina (from 72% to 37%).

Bay Area nonprofit KFF predicts 26% jump in ACA health insurance premiums in 2026

Centene Corporation saw its North Carolina footprint drop from 100% of counties in 2025 to 63% in 2026. This shift resulted from the exit of its subsidiary, WellCare, from that state’s Marketplace.

In Wisconsin, counties saw the exit of Chorus Community Health Plan and Molina Healthcare, alongside a reduced presence from CareSource, University Health Care, and Gundersen Lutheran.

Expert Insight: Samantha Carter notes that as enrollment declines, the risk pool may shift if healthier enrollees are more likely to drop coverage. This volatility could lead insurers to reassess profitability, potentially triggering further exits in 2027.

What happens to enrollment and plan options next?

Open Enrollment sign-ups for 2026 declined by more than one million people compared to the previous year. KFF estimates that total effectuated enrollment could drop by approximately five million people between 2025 and 2026.

Plan variety is also changing. In 490 counties—largely in Texas, New Jersey, South Carolina, Mississippi, Indiana, and New Mexico—some insurers have stopped offering bronze plans. This may reduce options for consumers seeking the lowest premium payments.

Because enrollment declines affect the potential market size, more insurers may decide to pull out of select states or the Marketplace entirely. Several companies have already announced departures for the 2027 plan year.

Frequently Asked Questions

Which states currently have the most ACA insurers?
Texas leads with 15 insurers, followed by New York (12), California (11), Florida (11), and Wisconsin (11).

Who are the most prominent insurers in the Marketplace?
UnitedHealth is the most prominent, operating in 30 states. Other major players include Centene Corporation (29 states), Oscar Health (20 states), and Elevance Health (18 states).

What is the legal requirement for plan offerings?
By law, every ACA Marketplace insurer must offer at least one silver and one gold plan wherever they sell coverage.

How do changes in your local county’s insurer options affect your healthcare choices?