The worst year for marketplace health insurance costs in a decade is about to get a sequel. Out-of-pocket premium payments rose 58 percent on average this year after enhanced subsidies expired, and now the window to make decisions opens again. Open enrollment for 2027 coverage starts November 1, 2026. On HealthCare.gov, December 15, 2026 is still the deadline for coverage to start January 1, 2027, and January 15, 2027 is the last day to enroll or change plans for 2027. For most households this is not a moment to auto-renew and move on.
What Changed and Why It Matters
From 2021 through 2025, enhanced premium tax credits made coverage cheaper and removed the income cap, so households above four times the federal poverty level could still get help. That expired at the end of 2025. Congress has not acted. Starting with plan year 2026 advance premium tax credit reconciliation, there is no limitation on how much excess advance premium tax credit you may have to repay if your income comes in higher than you estimated. For the self-employed and anyone with variable income, that is a material new risk sitting inside a policy that already costs substantially more.
Insurers point to three main drivers: rising underlying medical and prescription drug costs, a shrinking and higher-cost risk pool after healthier enrollees dropped coverage, and continued uncertainty about federal policy. Healthier enrollees tend to be the first to drop coverage once subsidies shrink, leaving carriers with a costlier remaining population to insure at the same premium. The math compounds with each wave of exits.
The Carrier Exodus
As of September 15, nine carriers have announced they will leave ACA marketplaces for plan year 2027, either in full or in selected states, according to KFF’s insurer participation tracker. Cigna, which covers about 369,000 marketplace enrollees across 11 states, will not offer marketplace coverage in any state in 2027. Molina Healthcare will cut more than half its presence, dropping from 14 states to about six. Centene (CNC) will reshuffle its brands in Delaware, New Hampshire, and Florida, moving affected members between subsidiaries.
In a number of states, more than one insurer has announced an exit, which leaves carriers that remain with less competition and consumers with fewer plan choices. A marketplace with only one or two insurers tends to have less pricing discipline than one with five or six competing. If your insurer leaves, your plan may be replaced automatically with one that has a different network and price. Check your renewal notice, and do not assume your doctor stays in network.
What Households Should Do Right Now
Insurers have proposed a median increase of about 15 percent for 2027. The weighted average proposed increase ranges from under 7 percent in Vermont, Iowa, and Utah to 29 percent in Arizona. That spread means the right move depends entirely on your state, your income, and your specific plan. Compare the full marketplace before December 15, not just your current carrier’s renewal offer.
Most enrollees will not absorb the full premium increase, since most marketplace enrollees receive a premium tax credit, but the new rules could be rough on anyone with fluctuating income. Running income estimates conservatively this year is not pessimism, it is protection against a repayment bill at tax time.
The Investment Read
For investors, the late-October earnings cycle is the first opportunity to see how badly attrition is accelerating into year-end. The hospital sector has already absorbed significant damage. HCA Healthcare said many uninsured patients had dropped ACA plans after losing enhanced subsidies, and now expects the increase in uninsured patients to lower its income by between $1 billion and $1.2 billion this year. HCA’s preliminary warning dragged down shares in Tenet Healthcare (THC) and Universal Health Services (UHS) as well.
UHS executives had originally assumed that some enrollees dropping ACA coverage would replace it with other commercial insurance. Instead, according to UHS CFO Steve Filton, “it felt like virtually everyone who lost their exchange coverage became an uninsured patient.” That dynamic is unlikely to reverse heading into 2027. Among the insurers still in the market, greater attrition carries the risk that medical costs of remaining members could eat up a larger share of premiums. Oscar Health (OSCR), which has staked its growth on the individual market, faces particular scrutiny as enrollment shrinks industrywide.
The Wealth Takeaway
The ACA marketplace is resetting a decade of subsidized stability in two years. For households, the single most valuable action before November 1 is an active comparison of every available plan, not a passive renewal. For investors, the Q3 earnings calls from HCA, Tenet, Elevance, and Centene will reveal whether enrollment losses are stabilizing or accelerating into the 2027 cycle. Positions in hospital operators carry the clearest near-term risk. The carriers still committed to the marketplace, those willing to hold share as competitors exit, may find better economics on the other side of this contraction. Getting there requires patience and a clear view of their remaining membership mix.
