ACA Stress Test: Four Key Takeaways From This Year’s Open Enrollment

Why It Matters

The ACA’s ability to retain a sizable risk pool despite the loss of enhanced tax credits preserves affordable coverage for millions and signals continued relevance for employers exploring HRAs.

Key Takeaways

• 23 million enrolled in 2026, 3.4 million new sign‑ups.
• North Carolina enrollment dropped 22 %; other states saw gains.
• Bronze plans now cover ~60 % of enrollments in Maine.
• HRAs gaining traction as employers seek cost‑stable alternatives.

Pulse Analysis

The 2026 open enrollment period served as a real‑world stress test for the Affordable Care Act after the enhanced premium tax credits expired on Jan. 1. CMS reported 23 million individuals securing coverage through HealthCare.gov or state exchanges, including 3.4 million newcomers. Although enrollment slipped slightly from the 2025 peak, the decline was far less dramatic than the collapse forecast by many analysts. The modest dip narrowed risk pools in certain markets, nudging average premiums upward, yet the overall participation level proved the individual marketplace remains a cornerstone of U.S. health coverage.

State‑by‑state results revealed a uneven landscape. North Carolina experienced the steepest year‑over‑year drop, roughly 22 %, while California, Maryland, Texas, the District of Columbia and New Mexico posted gains, the latter fully offsetting the loss of federal subsidies. These upward‑trending states are becoming fertile ground for health reimbursement arrangements (HRAs), as employers look to contain rising group‑plan costs while preserving employee choice. Policymakers eyeing midterm elections are likely to propose measures that boost affordability, which could further stimulate marketplace enrollment and HRA adoption.

Consumer preferences shifted decisively toward high‑deductible bronze plans. In Maine, bronze enrollment climbed to nearly 60 % of all selections, and 73 % of Californians who switched plans opted for bronze coverage. The trend reflects a trade‑off: lower monthly premiums in exchange for higher out‑of‑pocket expenses. CMS’s upcoming 2027 Notice of Benefit and Payment Parameters proposes expanding flexibility for these plans, a move that dovetails with HRA solutions that reimburse medical costs. Continued growth of high‑deductible options will shape premium dynamics and employer benefit strategies for years to come.