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The latest exits
Cigna said on April 30 that it will exit the ACA individual business at the end of 2026. Its plans cover 369,000 people across 11 states, and its incoming chief executive described the line as small and shrinking. Baylor Scott & White Health Plan said in April it will stop offering individual marketplace plans after 2026, affecting about 100,000 Texas enrollees. Aetna left the market at the end of 2025, forcing about 1 million people in 17 states to find new coverage.
Insurers that remain are pulling back. UnitedHealthcare expects to cut its ACA enrollment by roughly one-third this year to restore margins. Centene, the largest marketplace carrier, reported 3.6 million members in the first quarter, down from 5.6 million a year earlier.
A shift to bronze
Total marketplace enrollment reached 23.1 million for 2026, down 5% from 2025 after the enhanced premium tax credits expired. The mix moved more than the total. Bronze enrollment grew 26% to 9.2 million, and bronze plans now account for 40% of enrollees, up from 30%. The average monthly premium after tax credits rose to $178 from $113.
Payment behavior is also changing. An actuarial analysis reported in April found that about 14% of 2026 policyholders failed to pay their first premium, compared with mid-single digits in a typical year. In some states the rate topped 25%. Blue Cross Blue Shield of Arizona said it lost more than 30% of its 2026 ACA enrollees by late March, mostly to missed payments.
What hospitals should expect
- More patient responsibility. Bronze plans carry high deductibles, so a larger share of each bill shifts to patients who may struggle to pay.
- Grace-period risk. Enrollees who stop paying premiums can lose coverage retroactively, leaving claims unpaid for services already delivered.
- Network disruption. Each exit sends patients to new plans and possibly new networks, which can redirect volume.
- More uninsured visits. Some people dropping coverage will still need emergency and inpatient care.
Practical responses
Revenue cycle teams should verify eligibility and premium status at scheduling and again before service, estimate patient balances upfront and offer payment plans early. Financial assistance policies may need updating for insured patients with high deductibles, not only the uninsured. Finance leaders should track exchange volume, payer mix and bad debt by month to see the effect quickly.
Archive entry for May 9, 2026, added Nov. 11, 2026.