ACA Enrollment Decline in Texas: What It Means for Consumers

The number of Texans activating their Affordable Care Act (ACA) plans by paying their first month's premium declined by 4% this year, marking the first such decrease since 2019, according to newly released data from the Centers for Medicare and Medicaid Services (CMS). This shift comes despite Texas experiencing an increase in ACA enrollment at the start of the year, which was unexpected following the cessation of tax credits that had previously subsidized premiums.

The CMS figures indicate that the number of Texans with effectuated ACA coverage declined from 3.42 million in 2025 to 3.28 million in 2026 after higher premiums took effect due to the subsidy expiration. This downturn is the largest numeric decline tracked in Texas since CMS began collecting such data. Justin Lo, a senior researcher with KFF, noted, "We saw record growth in ACA enrollment when there was an enhanced premium tax credit...this is the first time we've seen a decrease in the enrollment."

Despite this decrease, Texas still performed relatively better than many states in 2026, with a national year-over-year decline of 12% in effectuated enrollments. Charles Miller from Texas 2036 commented, "The overall direction is down...And I think what the positive story is, is how well Texas did on that measure compared to other states."

The provisional CMS data show that 49 states experienced declines in effectuated coverage, though Texas saw a lesser drop than most. New Mexico was unique in registering growth, attributed to using state funds to replace the lapsed federal subsidies.

Impact of Premium Hikes on Consumer Preferences

The expanded ACA tax credits under the Biden administration had previously increased enrollment nationally by capping premium costs and broadening eligibility, accommodating low- or no-cost plans. The Texas marketplace, not having expanded Medicaid coverage, served as a crucial source of insurance for its low-income population. Texas' ACA enrollment reached approximately 4.17 million during the last open enrollment, though only 79% of these enrollees finalized their coverage by making first-month payments, the lowest rate in nine years.

The administrative data show premium hikes particularly affected silver plans, creating shifts in consumer plan preferences. The demand for bronze and gold plans increased as customers adapted to the altered cost dynamics, with silver plans losing their majority share for the first time in Texas since the ACA's implementation. The transition in plan selection is credited partly to Texas' premium alignment regulations enacted in 2022, which help maintain lower prices for bronze and gold plans, as highlighted by ongoing low average premiums for Texas enrollees, despite an increase from $57 to $89 monthly post-subsidy.

Texas' ACA market remains influenced by its unique policy landscape, including lack of Medicaid expansion and the adoption of premium alignment for silver plans. Lo remarked that the market's characteristics mean a continued reliance on ACA subsidies for many enrollees in the state.