Takeaways from Our ACA Exchange Actuary Call: Cautious Optimism in Early 2026, but Swing Factors Remain for 2027

Research evidence excerpt

Takeaways from Our ACA Exchange Actuary Call: Cautious Optimism in Early 2026, but Swing Factors Remain for 2027

eir relative size to other financial cohorts. We believe

this cohort (which comprised 10.7M signups or ~47% of all signups during the 2026

OEP by our estimates) remains under significant scrutiny, particularly in non-

Medicaid expansion states (based on our analysis of the 2026 OEP file, we estimate

~6.8M 100% to 150% FPL signups in FL, GA, SC, and TX alone in the 2026 OEP,

roughly flat vs 2025 OEP). Recent analysis suggests there may be a sub-section of

improper enrollment that could be affected by proposed program integrity changes

in coming years, shifting acuity in the ACA Exchanges higher. As a result, we believe

that as this group becomes a larger portion of the overall ACA Exchanges, it will

remain a key point to monitor (both for payors and investors) when assessing the risk

of further acuity shifts in the overall ACA Exchanges.

• Looking to 2027, the expectation appears to be for further contraction driven by

pricing increases. Axene expects enrollment to decline, but at a lower rate than in

2026. The assumption of further contraction is driven in part by the elevated

preliminary 2027 rate update requests, which he framed as in the range of 18% to

22%, dampening enrollment on affordability grounds. This is consistent with how we

have laid out expectations for 2027 marketplace enrollment with payors looking to

improve margins and navigate new policy factors, but with contraction nowhere near

the magnitude of contraction as in 2026. The natural question is: if 2027 sees further

contraction, will there be upward pressure from higher acuity as healthier members

exit? On this point, Axene suggested that 2027 should see an upward shift in risk