ACA Marketplace Insurer Participation Falls for First Time Since 2021 Tax Credit Expansion

The number of insurers offering plans on the Affordable Care Act (ACA) Marketplaces dropped to 9.0 per state in 2026, the first decline since 2021 when enhanced premium tax credits were introduced, according to data from the Kaiser Family Foundation (KFF). This follows the exit of Aetna CVS from 17 states and a broader shift in insurer strategies as tax credits expire.

National Trend: Insurer Count Falls to 9.0 Per State

Nationally, the average number of insurers offering ACA plans fell from 9.6 in 2025 to 9.0 in 2026, marking the first decline since 2018, when UnitedHealthcare exited most states, KFF reported. The drop coincides with the expiration of enhanced premium tax credits, which had boosted enrollment and insurer participation since 2021.

“The decline reflects both the loss of Aetna CVS and broader market adjustments as the temporary tax credits end,” said KFF analyst Emily Peters. “Insurers are reassessing profitability in a more stable but less subsidized environment.”

State-Level Shifts: 18 States See Net Loss of Insurers

Eighteen states experienced a net decrease in insurer participation, with Illinois and Michigan losing three carriers each. Conversely, Alabama and Washington added one insurer each, as Oscar Health entered Alabama and Elevance Health expanded in Washington, according to KFF’s 2027 Insurer Participation Tracker.

California, New York, and Texas remained the states with the most insurers, offering 11–15 plans each. UnitedHealthcare, the largest insurer, operates in 30 states, while Centene Corporation and Oscar Health each serve 29 and 20 states, respectively.

County-Level Impact: 165 Counties Face Single-Insurer Markets

Three in 10 counties saw a reduction in insurer options, with 165 counties now having only one carrier offering plans. In Wisconsin, Chorus Community Health Plan and Molina Healthcare exited entirely, while Centene’s footprint in North Carolina shrank by 37% as WellCare left the state, KFF data shows.

“Consumers in these areas may face limited choices, particularly for bronze plans, which 490 counties opted not to offer in 2026,” said Dr. Sarah Lin, a health policy expert at the University of Michigan. “This could affect affordability for lower-income shoppers.”

Enrollment Declines Signal Long-Term Challenges

KFF estimates that 2026 Open Enrollment sign-ups fell by over one million compared to 2025, with average effectuated enrollment projected to drop by five million by 2026. This could pressure insurers to further reduce participation, as healthier enrollees may opt out of the Marketplace, according to a 2025 Centers for Medicare & Medicaid Services (CMS) analysis.

“A smaller, sicker risk pool makes underwriting more challenging,” said CMS spokesperson Mark Reynolds. “We’re monitoring trends closely to ensure stability.”

Looking Ahead: Insurer Strategy Shifts

Several insurers, including Aetna and Blue Cross Blue Shield, have announced plans to scale back in 2027, citing financial pressures. Meanwhile, startups like Oscar Health are expanding, signaling potential long-term shifts in market dynamics.

“The ACA Marketplaces are evolving as subsidies phase out,” said Dr. Natalie Singh, a board-certified internist and health policy analyst. “Stakeholders must balance affordability with sustainability to maintain access for millions of Americans.”