The number of insurers offering plans on the Affordable Care Act's marketplaces declined between 2025 and 2026, with more payers poised for an exit ahead of the 2027 plan year, according to a new analysis.
Researchers at KFF released a look at trends in marketplace participation alongside a new tracker examining insurer activity for the coming year. In 2025, there was an average of 9.6 issuers per state offering plans, which declined to 9.0 for 2026, the report found.
A net decrease in marketplace participants was observed in 18 states, per KFF, and 165 counties had just one insurer participating, up from 93 in 2025.
Matt McGough, a KFF policy analyst for the program on the ACA and the Peterson-KFF Health System Tracker as well as one of the study's authors, told Fierce Healthcare that the massive enrollment increases brought about by the post-COVID enhanced premium tax credits made a number of payers see the potential in the marketplace.
"Insurers were seeing the ACA marketplaces as a good opportunity to grow," McGough said.
This year, the highest tally was 15 participating insurers in Texas, with several states with an average over 10—New York (12) and then California, Florida and Wisconsin average 11 carriers.
2025's average of 9.5 participants per state marked a record high following several years of steady growth with the enhanced tax credits in place. By comparison, for 2021, the year that the tax credits were implemented, there was an average of 7.7 participants per state on the marketplaces.
For 2022, that jumped to an average of 9.2 as payers returned or entered the market for the first time, KFF found.
The record-high averages also mark a significant turnaround from the marketplaces' lowest point; in 2018, participation averaged just 5.4 issuers per state.
Beyond the tax credits, the Centers for Medicare & Medicaid Services has finalized multiple changes aimed at ACA program integrity that are also impacting how insurers are approaching the exchanges.
McGough said that while the tax credits are likely the biggest culprit in the downturn, any additional uncertainty is sure to give payers pause.
"Any other changes that insurers are having to deal with just sort of worsen the pot for them," he said.
McGough said the 2026 number represents the first decline since the enhanced premium tax credits were put in place, and that is likely to carry into 2027. KFF said that as of June 8, six insurers have said they plan to fully or partially exit the exchanges for the coming plan year: Cigna, CareSource, PacificSource, Scott and White, Providence Health and Taro Health.
Cigna has about 350,000 members in its ACA plans, so its planned exit for 2027 represents a fairly small piece of its business, said McGough. The other plans represent smaller or more regional carriers, so the shift doesn't necessarily represent a "mass exodus" of national payers leaving the exchanges.
But it could be a sign of change to come, he said.
"These smaller insurers and Cigna could potentially act as a weathervane for how insurers are thinking about the profitability of the marketplaces," McGough said.
Even with these exits on the horizon, the KFF analysts said there aren't signs of a risk for "bare" counties, or regions with no participating insurers, which was a challenge during the exchanges' most unstable period.