A recent KFF report highlights a troubling trend in the Affordable Care Act Marketplaces: for the first time since 2021, insurer participation has declined, reverting to levels not seen since 2018.
The drop follows the expiration of enhanced premium tax credits that reduced costs for marketplace enrollees. These subsidies, which significantly boosted enrollment during their validity period, expired at the end of 2025.
Data shows the average number of insurers per state decreased to 9 in 2026—down from 9.6 in 2025—primarily due to Aetna withdrawing from operations in 17 states. This marks the first decline in insurer numbers since UnitedHealthcare’s large-scale exit in 2017.
KFF noted that while the marketplace stabilized post-2018’s market turbulence, including ACA repeal attempts and policy changes, the current decline reflects broader challenges. “The Marketplace stabilized in subsequent years as some insurers returned and expanded their offerings,” the organization stated, contrasting past recovery with current shifts.
Specifically, 18 states experienced a net reduction in issuers offering plans. Additionally, three in ten counties saw fewer participating insurers year-over-year, with 165 counties now having only a single provider—up sharply from 93 counties in 2025.
Enrollment trends further underscore the market contraction. KFF reported a decline of over 1 million sign-ups during the 2026 Open Enrollment Period and projected a potential drop of 5 million in “effectuated enrollment” nationally as fewer individuals maintain active coverage.
Aetna’s decision to exit underscores operational challenges. Citing strategic realignment, COO Katerina Guerraz stated at AHIP 2026, “ACA was not a space we excelled in… achieving success would have required a massive investment we were unwilling to commit.”
Cigna followed suit, announcing a 2027 exit from the marketplaces. President Brian Evanko highlighted scalability limitations and shifting organizational priorities: “It’s a small, shrinking business for us, with no clear path to significant impact at our scale.”
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