Significant Decline in ACA Enrollment in Ohio

Since the enhanced federal subsidies for Affordable Care Act (ACA) plans concluded in January, Ohio has reported the most significant decline in Marketplace enrollment across the United States. According to the Statehouse News Bureau, enrollments in Ohio's ACA plans fell by over 32% from February 2025 to February 2026.

Residents in rural areas using the ACA Marketplace, including Ohio, are experiencing higher coverage losses compared to their urban and suburban counterparts. Analysis from The Daily Yonder of the Centers for Medicare and Medicaid Services (CMS) data highlights these disparities in health insurance access.

The subsidies, initially introduced under the American Rescue Plan Act of 2021 and extended through the Inflation Reduction Act of 2022, expanded eligibility for reduced health insurance premiums. These federal benefits allowed individuals with incomes 400% above the Federal Poverty Level to qualify for subsidies. However, the non-renewal of these subsidies in late 2025 resulted in increased premiums for many Marketplace consumers, significantly impacting those who no longer qualify.

Nationally, ACA Marketplace enrollments have declined as premiums rose, particularly affecting rural areas. These regions experienced an approximate 12% reduction in sign-ups, equating to around 29,000 consumers. Small metropolitan counties saw a decline of 11%, affecting 154,000 consumers. Among the 30 states utilizing the ACA Marketplace platform in 2026, there was an overall 8% decline, impacting nearly 1.4 million consumers.

The CMS County-level Open Enrollment file, detailing plan selections, premiums, and demographics, informed this analysis. Notably, post-open enrollment sign-up rates often do not reflect the number of consumers maintaining coverage throughout the year. A KFF Health News survey highlighted that 9% of enrollees became uninsured after open enrollment, with 17% uncertain about future affordability.

The population earning above 400% of the Federal Poverty Level, with premium caps at 8.5% of income under Enhanced Premium Tax Credits, saw significant enrollment drops. They represented around 3% of enrollees but accounted for 27% of the decline between 2025 and 2026. This trend continued beyond the 30 states using ACA Marketplace platforms, also affecting those with state-based exchanges.

Lower-income individuals eligible for federal aid faced less severe premium hikes, maintaining more consistent enrollment. An analysis of premium increases post-tax credits showed nonmetropolitan counties being disproportionately affected, with many located in the highest premium increase quartile. States like Colorado and New Mexico implemented measures to mitigate subsidy expiration effects, with Colorado introducing a premium assistance fund and New Mexico achieving an 18% rise in ACA enrollments through state initiatives for health insurance affordability.