Anxious insurers wait to get paid as exchange sign-ups end

Modern Healthcare – Friday, January 16, 2026
By Nona Tepper

Visions of phantom exchange enrollees may be haunting health insurance executives as the open enrollment period winds down.

Thursday was the deadline for people to sign up for Affordable Care Act of 2010 plans in most states. Preliminary federal data show that sign-ups are down, but not as much as the nonpartisan Congressional Budget Office and others predicted.

Yet given massive premium increases and the expiration of enhanced tax credit subsidies at the end of 2025, health insurers are paying close attention to how many 2026 enrollees actually make their first premium payments and effectuate their coverage.

What will be the final tally for the 2026 open enrollment period is anyone’s guess, said Ceci Connolly, president and CEO of the Alliance of Community Health Plans, which represents nonprofit insurers.

“Anybody that tells you that they can draw conclusions of the numbers that we’re looking at today is definitely taking something that I’m not taking. It is still so up in the air and so uncertain. That is really difficult for health plans,” Connolly said.

With about two weeks left in the open enrollment period in most states, 22.8 million people had signed up for exchange plans, the Centers for Medicare and Medicaid Services reported Monday. That figure doesn’t include the last several days of sign-ups on some state-run exchanges ahead of the Dec. 31 deadline for coverage that started Jan. 1.

While down from 2025, 22.8 million would be the second-highest total since the marketplaces launched for the 2014 plan year and about twice as many people as in 2020, the year before the enhanced subsidies debuted.

Months will pass before a full accounting, but early evidence from some insurers and exchanges suggests a higher-than-usual share of exchange enrollees may not keep their plans this year.

In Pennsylvania, fewer people are paying for coverage or are downgrading to Bronze plans before the sign-up period closes, said Devon Trolley, executive director of Pennie, the state’s exchange. She expects the trend to continue as more people see their first bills this month. Open enrollment on Pennie ends Jan. 31.

An average of 1,000 Pennie enrollees is dropping out daily, and most of them are at the lower end of the income scale, Trolley said. Overall enrollment in Pennsylvania was down 3.68% to 477,950 as of Dec. 27, according to CMS. Pennie is also seeing a 15% decline in new customers, she said.

Group Health Cooperative of South Central Wisconsin is experiencing a similar phenomenon, said Marty Anderson, the insurer’s chief strategy and business development officer.

So far, most of the roughly 4,300 people who were automatically enrolled with the insurer because their previous carrier left the market haven’t paid their premiums, and the company doesn’t expect them to, Anderson said.

“We believe that the majority of them are going to end up being phantom members for us,” Anderson said. Group Health Cooperative of South Central Wisconsin has reached out to these new members more than a half dozen times already, he said. Exchange enrollment in Wisconsin was down 5.6% to 289,200 as of Jan. 3, according to CMS. Open enrollment on the federally run exchange in Wisconsin closed Thursday.

States that adopted policies to mitigate the rate hikes are seeing results so far.

New Mexico, for instance, devoted state dollars to essentially replace the enhanced subsidies, and enrollment was up 11.5% to 78,492 as of Dec. 27, CMS reported. The final deadline on the state’s BeWell exchange was Thursday.

Some states more aggressively engaged in the practice known as “Silver-loading,” which had the effect of enlarging premium subsidies. This policy allows insurers to “load” their expenses for federal cost-sharing reduction requirements for the lowest-income enrollees onto Silver-level plans.

While this inflates gross Silver premiums, it also leads to lower net premiums for subsidized enrollees because the value of the assistance rises along with the price of the second-cheapest Silver plan in each geographic market. That can make Silver plans less expensive and Bronze plans available with $0 premiums.

Connecticut credits Silver-loading, a state-financed premium support program and its public education campaign for enrollments that exceeded expectations, said James Michel, CEO of Access Health CT, the state exchange.

Access Health CT anticipated that sign-ups would plummet 25%, Michel said. But according to the CMS data, enrollments were down 1% to 149,523 as of Dec. 27. “We are very pleasantly surprised,” Michel said. Open enrollment ends Jan. 31 in Connecticut.

Sign-ups grew 3.7% to 4.1 million in Texas as of Jan. 3, according to CMS. That can be attributed to its Silver-loading program, said Katherine Hempstead, a senior policy advisor at the Robert Wood Johnson Foundation, a philanthropy that funds health research. The enrollment period ended Thursday for federally operated marketplace in Texas.

“If your state didn’t really ‘Silver-load’ like Texas, your tax credit’s not going to go that far,” Hempstead said.

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