Open enrollment on the ACA exchanges is set to begin. Here are 5 trends to watch

Open enrollment on the Affordable Care Act's (ACA's) exchanges is set to begin, but signing up for coverage remains confusing for many, a new analysis shows.

That's one of several trends to watch during the sign-up window, which begins Nov. 1 and runs through Jan. 15, according to experts at KFF. As part of its annual look at consumers' experiences with insurance, the researchers polled more than 3,600 adults in the U.S. who have coverage.

The study found that more than a third (35%) of people enrolled in marketplace plans find it either somewhat or very difficult to find the right coverage.

That's significantly high compared to people enrolled in other types of plans. Just 15% said the same for Medicare, 17% for employer-sponsored plans and 19% for Medicaid.

"Marketplace coverage is unique as it often operates as a transitional source of coverage for millions of people when they find themselves ineligible for employer-sponsored coverage or coverage such as Medicaid or Medicare," the KFF researchers wrote. "There is a high degree of churn in and out of Marketplace coverage, and those signing up for the first time for this coverage will be unfamiliar with the process."

Outreach and access to key information varies between states and marketplaces, too, the KFF analysts noted. People are also faced with "option overload," which can make it difficult to select a plan.

Here are four other open enrollment trends to watch, courtesy of the experts at KFF.

Enrollment could reach record highs yet again

Sign-ups for exchange plans have continued to set records, with 15.7 million people choosing a plan during the 2023 open enrollment period, surpassing highs in 2021 and 2022.

Earlier this year, states began to resume eligibility determinations in Medicaid, and KFF's data show that 9.5 million people have been booted from Medicaid and the Children's Health Insurance Program so far under this process, largely due to procedural reasons. There are likely people in this group who qualify for subsidies on the ACA exchanges, which could drive higher enrollment.

Overall, enrollment in marketplace plans largely plateaued between 2015 and 2016, before changes in response to the COVID-19 pandemic drove sign-ups to spike in 2022 and 2023.

Inflation is driving up premiums

While most people who secure coverage on the ACA exchanges qualify for subsidies that significantly lower the cost of premiums, unsubsidized premiums are on the rise. 

KFF projects that premiums for the second lowest cost silver plan, or the benchmark the feds use to determine subsidies, will rise by 5% on average for 2024. Premiums for the lowest cost bronze plan are set to rise by 6% on average, KFF said.

Rising inflation as well as a return to more normal utilization rates as the pandemic recedes are key factors in driving up premiums. Serving as a counterweight, however, are expanded subsidies rolled out by the Biden administration that ensure large swaths of the population are "sheltered from the sticker price of the premium," according to the analysis.

State-level changes could have a wide array of impacts

Changes in individual states could impact multiple facets of the enrollment period depending on where potential enrollees are living, according to the report. For example, California will offer additional cost-sharing reduction subsidies that will lower out-of-pocket costs and deductibles.

These additional subsidies are likely to reach 4 in 10 people enrolled in Covered California, KFF said.

North Carolina, meanwhile, will expand its Medicaid program beginning Dec. 1, which could lead to people who would otherwise be in exchange plans making the switch to Medicaid.

And in Washington state, undocumented immigrants can begin to sign up for plans using income-based subsidies for the 2024 plan year.

More insurer entrants than exits for 2024

While there are some notable exits for the coming year, KFF said insurer participation in the exchanges is set to overall be more robust than in years past.

Oscar Health will depart the California market due to disappointing profits, and Cigna will exit Kansas and Missouri, according to the report. However, other insurers are entering new states, including California, Colorado, Delaware, Indiana, Maryland, Nevada, New Jersey, New Mexico, Oklahoma, Pennsylvania, South Carolina, Utah and Wisconsin.

"There are more insurers entering new markets than there are plans exiting from the Marketplace," the analysts wrote.