The ACA individual market risk pool is getting smaller and sicker, with risk scores rising 6.3% even as enrollment fell 12% through April, according to a July report from Wakely.
The analysis drew from data representing nearly 80% of individual market enrollment across 37 states.
Six notes:
- Enrollment in the ACA individual market fell 12% in the first four months of 2026 compared to the same period a year earlier. The decline is expected to deepen as the year progresses, with Wakely estimating full-year enrollment losses of 19% to 23%.
- Relative risk scores rose 6.3% year over year. The increase was consistent across all four months and across state-run exchanges, federal exchange states that expanded Medicaid and federal exchange states that did not. Silver-tier plans saw the steepest risk increase at 15.8%, likely driven by healthier, lower-income enrollees buying down to bronze or gold from cost-sharing reduction plans.
- The share of enrollees with claims ticked up just 0.2%, suggesting the overall proportion of people using services is largely stable. But the share of enrollees with at least one hierarchical condition category rose 0.6%, meaning those who are using services tend to be higher-acuity.
- Federal exchange states that expanded Medicaid saw the sharpest enrollment declines at 23.3%, with nearly 60% of remaining members enrolled in bronze plans, up from 42% a year earlier. Silver enrollment in that cohort collapsed by nearly 50%.
- State-level variation has been significant, with some states seeing enrollment drop more than 25%, while others barely declined at all. Risk score changes ranged from 2.5% to 11.1% across the same spread. Wakely noted that states with larger enrollment losses generally saw higher risk increases, but the relationship wasn’t uniform, so the morbidity shift is not purely a function of who left.
- The report noted that early risk scores may understate the full-year morbidity shift because high member churn between issuers is creating claims and coding lags. Wakely said it expects morbidity to worsen further as the year progresses. Insurers offering coverage for 2027 have pitched a median rate increase of 15%, the second consecutive year of double-digit hikes.
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