The average number of insurers offering plans on the Affordable Care Act marketplaces has dropped for the first time since 2018, falling from a record high of 9.6 per state in 2025 to just nine in 2026, according to a report published last week. The decline comes as the exchanges face federal policy uncertainty and rising costs. Three in 10 U.S. counties now have fewer ACA insurers than last year. In 165 counties, only one carrier is offering plans on the exchange — up from 93 areas in 2025.
The analysis said the drop marks the first time the average number of health plans in the ACA marketplaces has fallen since 2018.
That trend is tied to falling sign-ups and expiring financial assistance.
Why health plans are pulling back from the marketplaces
One major driver is the expiration of enhanced premium subsidies at the end of 2025. Republicans in Congress refused to extend the more generous financial assistance, causing premiums to spike. That pushed many Americans to drop coverage or shop for cheaper plans. Enrollment in the ACA platforms has already declined by more than 1 million people since last year, and researchers expect more beneficiaries to fall off during 2026 as they fail to pay the higher rates.
As Americans leave the exchanges, more health plans could follow, worried about profit margins from covering a smaller and likely sicker population.
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Some big names have already left.
County-level shifts and state-by-state differences
Despite the flurry of exits, the number of ACA payers varies widely across states.
Four states bucked the trend: Alabama, Iowa, Louisiana, and Washington each had a net increase of one carrier.
Even where a payer continues to operate statewide, companies may still shift their footprints within different areas. Areas in Wisconsin had the highest number of provider exits, the analysis found. Some regions in North Carolina and Michigan also experienced significant decreases.
The pattern echoes the early years of the ACA.
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When payer participation was volatile and many areas faced bare or near-bare markets, the risk of being the only carrier in a locality often led to higher costs and limited choices for consumers.
Now, with the same number of areas down to a single provider, that risk is back.
The difference is that the ACA itself is no longer new.
The marketplaces have been running for more than a decade, and the current pullback is tied directly to a political decision — the expiration of enhanced support — rather than to the teething problems of a new system. The study does not forecast whether more health plans will leave this year, but it notes that participation levels could fall further if sign-ups continue to shrink. The number of people who pay their monthly costs and maintain coverage is a key metric for payers; when that number drops, the remaining pool tends to be sicker and more expensive to cover.
