A new analysis from KFF shows that for the first time since the enhanced premium tax credits were introduced in 2021, insurer participation in the Affordable Care Act Marketplaces has fallen.
The tax credits reduced premiums for individuals purchasing coverage on the Marketplaces and expired at the end of 2025.
KFF’s analysis found that the average number of issuers offering plans on the Marketplaces declined to 9 issuers per state in 2026, compared to 9.6 issuers per state in 2025. This is largely due to Aetna’s exit from 17 states. This is also the first time since 2018 that the average number of insurers participating in the ACA marketplaces has dropped.
“Insurer participation on the ACA Marketplaces fell in 2017 with the exit of UnitedHealthcare from most states. In 2018, following several attempts to repeal the ACA in Congress as well as changes to enforcement of the individual mandate and payments for cost-sharing reductions, many more insurers exited or scaled back their participation,” KFF said. “As the Marketplace stabilized in the following years, participation in the ACA Marketplaces steadily grew with some insurers returning to the Marketplace and several others expanding their footprints.”
KFF also found that 18 states in total saw a net decrease in the number of issuers offering ACA Marketplace plans.
In addition, three in 10 counties have fewer participating ACA insurers than last year. In 165 counties, there is just one issuer offering ACA Marketplace plans, compared to 93 counties in 2025.
A major factor leading to the number of insurers leaving the Marketplaces is how many people have coverage, according to KFF. The researchers noted that enrollment reached record highs after the enhanced premium tax credits were introduced, which led to the number of insurers offering ACA Marketplace plans increasing significantly in 2022.
“Data shows that after the expiration of the enhanced premium tax credits, 2026 Open Enrollment Period sign-ups declined by over one million people relative to last year; and the number of people who pay to maintain and ‘effectuate’ their coverage will likely decline throughout the year,” KFF said. “KFF estimates that average effectuated enrollment in the Marketplaces could decline by about five million people from 2025 to 2026.”
In a recent interview at AHIP 2026, Aetna COO Katerina Guerraz discussed why the company chose to exit the ACA Marketplaces in 2026.
“That wasn’t a business that we were very good at and very successful at. … It was a massive reset of Aetna’s strategy and where we were operationally,” she said. “When we looked ahead and said, ‘What are the things that we think we’re good at, how we serve 27 million people today,’ … ACA wasn’t one that I would tell you we were great at, and would have required a massive investment for us even to try and figure out how we can be successful for our members in that space.”
Cigna also announced that it is exiting the ACA Marketplaces in 2027. On the insurer’s April 30 earnings call to discuss first quarter results, Cigna President and COO Brian Evanko said there were two main reasons the company chose to step away from the individual exchanges.
“One, we did not see a clear path to scale this business to achieve meaningful impact within the context of The Cigna Group’s aggregate size,” he said. “And the second factor is management focus for the organization. This is a small business for us today, and it’s been shrinking in recent years.”
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