The Waiting Room | Trump's 'Great Healthcare Plan' Scam
And while millions are dealing with sticker shock over their premiums, residents of nine states still have a few days to enroll in ACA coverage.
Charles Gaba is a health care analyst who tracks policy and politics at ACASignups.net. Subscribe to his Substack!
Greetings, Lincoln Square readers!
When we left off, the U.S. House had kicked the enhanced ACA tax credit ball back over to the U.S. Senate, where a bipartisan group of Senators spent a week or so scrambling to put together something which could garner 60 votes in the Upper Chamber.
The brouhaha over ACA subsidies and skyrocketing premiums even forced Donald Trump to finally roll out his much-ballyhooed & widely ridiculed “healthcare plan” a full decade after he first promised it … and as expected, it amounted to a big nothingburger.
Unfortunately, not only does the Senate’s version of “something” include several poison pills, it also quickly went from being on the brink of getting a vote … to the legislative text being delayed until the end of January… otherwise known as right about now.
This also happens to coincide with the end of the Continuing Resolution…except that the enhanced ACA subsidies have been overshadowed this time around by the outrage & backlash vs. DHS & ICE over their brutal, out of control reign of terror & murder in Minneapolis and elsewhere.
I’ll admit that I was beginning to wonder whether the Senate “compromise bill” would ever see the light of day, but sure enough, this week Sen. Bernie Moreno (R-OH) posted the GOP’s “Final Offer” legislative text … and it’s a dumpster fire.
In any event, it’s time to take a look at the 2026 Open Enrollment Period (OEP) numbers. While it’s still happening in some states (see below), the final deadline passed on Jan. 15th in most states.
Yesterday the Centers for Medicare & Medicaid Services (CMS) published an updated 2026 Open Enrollment Period report, putting the grand (semi-final) total at 23 million Qualified Health Plan (QHP) selections.
While this is officially “only” 1.3 million fewer (still a lot losing coverage!) than the final 2025 Open Enrollment tally, there’s some vitally important caveats to keep in mind, as I warned back in December:
Up to half the ~19.6 million renewing enrollees passively auto-renewed, meaning many didn’t find out how much their premiums skyrocketed until they received their January invoices, likely leading to many terminating their coverage before it even began.
Many more will only be able to keep up with the payments for a few months before being forced into dropping their coverage.
A dozen or so states have initiated programs to either temporarily backfill some or all of the lost federal subsidies or to reconfigure plan pricing in order to mitigate the damage for many enrollees.
In addition, millions of those who have enrolled for 2026 coverage (my own family included) were forced to significantly downgrade their coverage to worse plans with dramatically higher deductibles & other out of pocket costs
WITH THAT IN MIND …
I’ve plugged in the semi-final 2026 OEP totals and compared them against the final 2025 OEP numbers. Note that since ILLINOIS transitioned from the federal exchange (HC.gov) to a state-based marketplace (SBM) this year, I shifted the final 2025 OEP enrollment data over to the SBM category accordingly:
Overall Qualified Health Plan (QHP) plan selections are down 5.5% year over year. New enrollment is down 18%, while there are 3% fewer returning enrollees.
The overall drop isn’t too different between federal & state-based exchanges (5.4% & 5.9% respectively), but there’s a huge difference in the new vs. renewing enrollee breakout:
HC.gov states saw new enrollment drop 7.8% & renewals drop 4.9%
SBM states saw new enrollment drop a whopping 38% (again, this is a bit misleading due to some SBM data still missing)...but renewals increased by 1.2%
The total of the state by state breakout below is around 37,000 higher than the 2026 summary total above due to my having more recent enrollment data for 9 of the SBM states (CA, CO, CT, ME, MD, MA, NV, NM & WA). I’ve included a column to note how many days of enrollment data are still missing for 13 of the SBM states:
The extra data from those states brings the shortfall down slightly to 5.4% year over year (-1.31 million). The stragglers yet to be added might tack on another ~40,000 or so to the total at most.
In addition, there’s ~1.86 million enrolled in Basic Health Plan (BHP) programs in D.C. (new this year), Minnesota, New York, and Oregon. This is up 5.9% year over year.
BHP enrollment is expected to plummet by ~450K this July, however, due to the subsidy cuts forcing NY to restrict their Essential Plan program to far fewer people.
I’ve also broken out the year over year totals in other ways, including federal vs. state-based exchanges (again, not much difference overall) & Medicaid expansion vs. Non-Expansion:
While the official net drop in plan selections during Open Enrollment “only” ended up being around 1.3 million (still a lot of people losing coverage!), it’s important to remember that up to 10 MILLION of the ~19.6M enrollees who re-enrolled did so by passively auto-renewing, which means millions of them received massive sticker shock when they received their January invoice.
As I noted a few days ago, at least a half-dozen of the state-based exchanges have warned that they’re already seeing much higher cancellations than they usually do, and that they expect this trend to continue as people are no longer able to keep up with the dramatically higher premium payments.
I expect several million more to terminate coverage over the next few months, leading to a likely monthly average effectuated enrollment of somewhere between 18.2 to 20.8 million … which would put actual 2026 ACA exchange enrollment lower by up to 4.2 million vs 2025 …
Which, as it happens, would be right in line with what the Congressional Budget Office (CBO) projected back in July 2024, in spite of the Wall Street Journal’s editorial board completely misrepresenting both the CBO projection as well as the CMS snapshot report.
This would be in line with 2015-2020 patterns: Peaking early in the year before gradually dropping off, as opposed to the more recent years (when enhanced subsidies were in place):
HAVING SAID ALL OF THAT…
New Mexico is up 17.1% year over year, thanks to the state backfilling 100% of all lost federal tax credits for all enrollees!
7 other states (Texas, Maryland, D.C., Idaho, Connecticut, Louisiana, and Massachusetts) are also up year over year, although not nearly as dramatically.
The big surprise is TEXAS, which is up 5.2%. While Texas does have an very robust Premium Alignment initiative which definitely helps mitigate the expired tax credits, they’ve already had this program in place for the several years now, so I assumed that most of the enrollment benefits were already baked into the mix. I guess not!
At the opposite end of the spectrum, North Carolina has seen enrollment plummet a whopping 22%. Other states which dropped by more than 15% include Ohio, West Virginia, Indiana, Delaware, Arizona, Oregon and Oklahoma.
In terms of raw number losses, North Carolina, Georgia, and Florida lead the way with each losing ~200,000 enrollees apiece. This is in sharp contrast to Texas, which again gained over 200,000 enrollees.
As for premium changes, that data won’t be available for most states until the official 2026 OEP report is released by CMS (likely in April), but California has provided a breakout of their semi-final data:
It’s important to keep in mind that California is fully backfilling 100% of the lost subsidies for all enrollees earning less than 150% of the Federal Poverty Level (FPL)…which explains why net premiums for those ~287K enrollees are actually lower than they were last year.
For the remaining ~1.6 million enrollees, however, the net increases range from 9% to 84% for those in the 400 - 600% FPL bracket. The overall average is 35%, although this would be 51% without the < 150% FPL enrollees.
Imagine what the net hikes would look like if California wasn’t covering a big chunk of the lost credits and you begin to get an idea of how ugly it is in most states.
Meanwhile, residents of 8 states and D.C. (around 30% of the total U.S. population) still have until Saturday night (Friday for Virginia) to enroll in ACA exchange healthcare coverage effective February 1: California, Connecticut, District of Columbia, Illinois, New Jersey, New York, Pennsylvania, Rhode Island and Virginia.
And with that, I’ll see you again in … two weeks!
The Republican health plan is unchanged now for several decades. Basically, the plan says, "If you get sick, please die quickly."
As long as the USA as a whole and our elected cretins are unwilling to admit that health care is a basic human right and not a privilege, it's not going to change.
If we took all the money that this administration has plowed into international pirate adventures and domestic terror attacks on Americans, and focused it on healthcare and benefit for Americans, we could make life better for us all.