The Peterson-KFF Health System Tracker's review of 312 insurers across all 50 states and the District of Columbia found a median proposed 2026 premium increase of 18%, with the benchmark second-lowest-cost silver plan up 21.7% on a weighted basis. Only four of the 312 proposed a decrease.

The more useful number is inside the filings. One insurer applied a 1.044 morbidity adjustment for anticipated risk pool deterioration. Another, in the same regulatory environment and working from the same CMS enrollment data, applied 1.0025.

Key Takeaways

  • One hundred and twenty-five of the 312 insurers filed for 20% or more, against a 25th-to-75th percentile range of 12% to 27%, after a 2020-to-2025 stretch in which annual ACA premium growth averaged roughly 2.0%.
  • The subsidy expiration contributes about 4 percentage points of the total on average, and carrier morbidity adjustments for it span 1.0025 to 1.044, a factor of nearly 18 on the same federal change.
  • Only 86% of enrollees paid their first premium in January 2026 on Wakely's data, and payers carried 10% higher morbidity in aggregate than non-payers, which confirms the direction the filings assumed.
  • 23.1 million plan selections against projected effectuated enrollment of 16.5 to 18.5 million is the earned premium shortfall carriers who priced a 1.02 to 1.04 adjustment are exposed to.
  • Bronze share moved from roughly 30% to 40% while Silver fell from 56% to 42%, which moves the denominator in the statewide average premium that risk adjustment transfers are calculated against.

What the 21.7% Is Made Of

Filed rates layer a base experience period, a projected medical trend, and adjustments for enrollment composition, regulation and external cost. The 2026 filings separate into four drivers plus residual.

Rate DriverEstimated ContributionKey Assumption
Medical cost trend (unit cost + utilization)~8 percentage points7-8% underlying trend; hospital labor costs, procedure volumes
Enhanced subsidy expiration (morbidity shift)~4 percentage pointsHealthier enrollees exit; 2.9-6.5% morbidity increase
GLP-1 and specialty pharmacy~3-5 percentage points25-30% quarterly utilization growth; 2% of members, 50%+ of drug spend
Tariff-related medical cost uncertainty~3 percentage pointsImport costs for drugs, devices, supplies
Residual (risk adjustment, admin, margin)~2-4 percentage pointsAdministrative cost inflation, profit and risk loads

Medical trend is the largest and the least novel: insurers started from roughly 7% to 8% underlying trend, citing hospital labor costs, post-pandemic utilization recovery and general inflation. That is consistent with the Segal Group's 8.5% projection for large group and PwC's 8.0% estimate for 2026, so the individual market is not pricing something the rest of the system is not seeing.

Pharmacy is where the trend assumption gets unstable. MVP Health Plan of Vermont disclosed GLP-1 costs rising 25% to 30% per quarter during 2024, with Q4 2024 nearly doubling the full-year 2023 total, while Kaiser Foundation Health Plan of Washington projected an 18% utilization increase for 2025 and a further 7% for 2026. Blue Cross Blue Shield of Massachusetts discontinued weight-loss GLP-1 coverage entirely and estimated it would cut premiums by about 3%, against net prices of $617 to $766 per 30-day supply.

Tariffs are the newest line, at roughly 3 percentage points where carriers included them, covering imported drugs and devices. Some carriers loaded nothing, which is a discretionary difference rather than an actuarial one.

The Same Expiration, Priced Eighteen Ways

The enhanced premium tax credits expired December 31, 2025, and the filings show that carriers agree on the mechanism and disagree by an order of magnitude on its size.

CarrierStateMorbidity Adjustment FactorRationale
UnitedHealthcare (Optimum Choice)Maryland1.044Healthier members exit at disproportionately higher rate
Wellpoint WashingtonWashington1.016Anticipated statewide average morbidity change
MVP Health PlanNew York1.0025Market-wide index rate adjustment

UnitedHealthcare's Optimum Choice filing in Maryland states the reasoning directly: "UHC anticipates a decline in enrollment due to higher post-subsidy premiums, with healthier members expected to leave at a disproportionately higher rate than those with significant healthcare needs, increasing market morbidity in 2026." The 1.044 factor is a 4.4% expected increase in average per-member morbidity from composition change alone, with no assumed change in anyone's health status.

MVP's 1.0025 in New York carries a morbidity load nearly 18 times smaller for the same federal expiration. The gap is not a disagreement about whether healthier members leave. It is a disagreement about state-level enrollment elasticity, the composition of each carrier's existing book, and how much state premium alignment will absorb.

The January data settles the direction, if not the magnitude. Wakely found only 86% of enrollees paid their first premium, with non-payment above 25% in some states, and that the enrollees who did pay carried 10% higher morbidity in aggregate than those who did not. That is the adverse selection the filings assumed, measured a month into the policy year.

It also sizes the exposure. Wakely projects effectuated enrollment falling 3.8 million to 5.8 million during 2026 once non-payment, mid-year attrition and SEP churn are counted, against CMS's 23.1 million plan selections. A 17% decline lands near 18.5 million effectuated; 26% lands near 16.5 million. A carrier that filed a 1.02 to 1.04 morbidity adjustment is earning premium on the smaller number while covering the morbidity of whoever remains, and the two errors compound rather than offset.

The Denominator Is Moving Too

The complication is that the same filings changed the basis on which the corrections would be measured, in two places.

Metal level selection is the first. Bronze enrollment rose 26% year over year while Silver fell 28%, taking Bronze from roughly 30% of selections to 40% and Silver from 56% to 42%. That is subsidy mechanics rather than preference: the benchmark Silver plan was near-free for many low-income enrollees under the enhanced credits, and Silver carries cost-sharing reductions below 250% FPL, so its net premium moved most when the credits lapsed.

Gold rose from 13.2% to 17.2%, a gain of nearly 770,000 enrollees, which points to higher-income members who had gained eligibility above 400% FPL buying richer coverage rather than leaving.

Risk adjustment transfers are calculated against a statewide average premium, and that average is now being computed over a materially different metal distribution than the one that generated the historical transfer positions. A carrier whose 2025 book skewed to Silver can see its transfer position move without its own risk profile changing at all.

Premium alignment is the second. About a dozen states run it for 2026, with Arkansas, Illinois and Washington newly adopting in response to the credit expiration. It concentrates the cost-sharing reduction load onto on-exchange Silver plans, raising Silver premiums to generate larger tax credits while keeping Bronze and Gold competitive. Washington's benchmark increase came in at 21.2% with only 2.3% attributable to subsidy expiration; Arkansas landed at 26.2% with roughly 7 points from it.

That difference is not a difference in how the two states' populations respond to losing a subsidy. It is a difference in how the loss reaches a net premium. A filed morbidity factor of 1.016 in an alignment state and 1.016 in a state without it are describing different exposures, and the filed number does not distinguish them.

Further Reading

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