The Waiting Room | You Can Weigh in on Trump's ACA Changes Now

But hurry ... the deadline to comment is March 13. Plus, an update on the latest on ACA, Medicare, and Medicaid enrollment numbers.

Charles Gaba is a health care analyst who tracks policy and politics at ACASignups.net. Subscribe to his Substack!

Greetings, Lincoln Square readers!

In the last edition, I broke out a dozen or so proposed changes to how the ACA individual market/insurance exchanges are administered that the Trump Regime has planned, most of which range from bad to horrible.

The good news is that you still have until TOMORROW (March 13th) to submit public comments on all of these proposed changes (using this form).

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This week I have a hodge-podge of updates for you, starting off with …

New Jersey posts final Open Enrollment report:

While the official 2026 ACA Open Enrollment Period report for every state likely won’t be published by the Centers for Medicare & Medicaid Services (CMS) until late April or early May, a few states have started publishing theirs.

The NJ Department of Banking & Insurance recently put out a press release with their final 2026 ACA OEP report:

Enrollment Expected to Decline As Federal Changes Continue to Impact Affordability

TRENTON — More than 509,000 New Jersey residents enrolled in health insurance coverage for 2026 through Get Covered New Jersey, the state’s Official Health Insurance Marketplace, during the Open Enrollment Period. However, the state is cautioning that the full effect of the loss of federal subsidies has not impacted the marketplace yet and is predicting a material drop off in enrollment this Spring.

Of the 509,192 residents enrolled during the Open Enrollment Period, which ran from November 1, 2025, to January 31, 2026, there were 297,903 new or existing consumers who actively selected a plan and 211,289 who were automatically renewed from 2025.

Federal changes significantly impacted all Affordable Care Act (ACA) health insurance marketplaces around the country, including Get Covered New Jersey. Congressional inaction on extending enhanced premium tax credits, in addition to federally imposed changes to the program, have resulted in a significant number of enrollees receiving less or no federal financial help. Consumers are now burdened with higher premiums and out-of-pocket costs for most health insurance plans in 2026.

I’ve gone through the report itself, as well as the same report from last year.

New enrollments are down 31% year over year, but this was mostly made up for by existing enrollees re-enrolling for 2026 ... with a dramatic increase in the number who actively selected a new policy this year, thankfully. Overall enrollment ended up only down about 0.8%, although again, there’s a huge difference between the number of plan selections during Open Enrollment and actual effectuated enrollment over the course of the year.

Nearly 44,000 enrollees who received federal tax credits in 2025 are no longer eligible this year.

Perhaps most significantly, as noted in the press release, there was a significant drop in the number and percent of enrollees who selected Silver or Gold plans (down 12% & 15% respectively) ... paired with a dramatic increase in Bronze & Catastrophic plans (up 60% & 63%, respectively) as people desperately tried to avoid or at least mitigate the premium hikes by taking on higher out of pocket costs instead.

The NJ report also breaks out the net monthly premiums by different brackets, although I prefer to do it more granularly:

• Last year, nearly 42% of all NJ enrollees only paid $1 or less per month after subsidies; this has dropped to just 7.5% of the total

• Last year 46.6% paid $10 or less; this has dropped to just 9.7%.

• At the upper end, last year 37% of all NJ enrollees paid more than $100/month; this has jumped to nearly 56% of the total

Put another way, the number of enrollees paying $10 or less/month has dropped by 78% ... while the number paying more than $100/month has increased by a 50%.

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Oregon and Oklahoma Joining the State-Based Exchange Trend:

Way back in 2015, right after the U.S. Supreme Court ruled on the infamous King vs. Burwell lawsuit (which attempted to strip ACA subsidies from anyone living in states who utilized the federal exchange, HealthCare.Gov … over 2/3 of them at the time), I noted the following:

The main reason for pushing for 51 separate websites in the first place was mainly just an attempt to win over a few conservative “states rights” votes in Congress from Republicans and some conservative Democrats. There were some practical advantages to doing it this way, as well …

… it turned out to be a good thing that there were over a dozen state-run websites … because many of them helped mitigate the worst of the damage during the early, ugly days of HealthCare.Gov …

I went on to note that with the politics of the King vs. Burwell case having been settled, states might actually be more likely to strike out on their own platform instead:

… It’s even conceivable that a few years from now, after 1) The ACA has become even more firmly entrenched nationally; 2) the software/technology for running a state exchange has become even more streamlined, simplified, faster, easier to use, cheaper, etc etc; and 3) (hopefully) some changed attitudes/changed administration officials (ahem), a few states on HC.gov now may even decide to go ahead and move onto their own “full” exchange/website after all...completely of their own volition.

I realize that sounds pretty crazy now (since there’d be no financial incentive to do so), but anything’s possible ... and with King out of the way, at least that’s a viable option now.

Sure enough, that’s exactly what happened:

• February 2018: Nevada begins re-launching their own ACA exchange

• October 2018: New Mexico announced a move to their own ACA exchange

• June 2019: New Jersey passes a bill establishing its own ACA exchange

• June 2019: Pennsylvania moves to establish their own ACA exchange

• January 2020: Maine announces a move to thier own ACA exchange

• October 2020: Kentucky re-launches their own ACA exchange

• February 2023: Georgia, after originally attempting to scrap any ACA exchange at all, grudgingly agrees to go the other way and establish their own (it launched in November 2024)

• May 2023: Illinois passes a bill establishing their own ACA exchange (it didn’t actually launch until last November)

• November 2023: Virginia launches their own ACA exchange

As of today, 21 states (with DC) operate their own state-based ACA exchange platform, including CA, CO, CT, DC, GA, ID, IL, ,KY, ME, MD, MA, MN, NV, NJ, NM, NY, PA, RI, VT, VA & WA. This is up from 15 states back during the first Open Enrollment Period in 2013-2014.

Since then, a few states have actually bounced back & forth between the federal exchange at HealthCare.Gov and their own platform:

• Hawaii had a state-based exchange (SBE) for the first two years of Open Enrollment before being forced into shutting down and moving back to federal exchange control due to both serious technical and management problems.

• Nevada had an SBE for the first year, had to scrap it & move back to HC.gov after major technical problems, then re-launched a new SBE in 2019.

• Kentucky had an SBE which operated smoothly for several years until Republican Governor Matt Bevin shut it down for no particular reason...only for his successor, Democratic Governor Andy Beshear re-launched a new version of it four years later.

• Both Idaho and New Mexico were hosted by the federal exchange for the first few years of the ACA before splitting off from it onto their own SBEs, but these were already in the works from Day 1; they just took a couple extra years to put into place.

• And finally, there’s Oregon, which, like Nevada, originally had their own SBE but saw it fail spectacularly out of the gate, as immortalized in this fun John Oliver bit at the time:

Like Nevada and Hawaii, Oregon was forced by massive technical glitches to scrap their SBE and move home to the mothership ... but, like Nevada did in 2019, over a decade later, the Beaver State is taking another crack at it this fall:

Senate Bill 972 (2023) requires OHA to transition the Marketplace from a state-based marketplace using the federal platform (SBM-FP) to a state-based marketplace in time for open enrollment for plan year 2027. Specifically, OHA is required to procure and administer both an information technology platform and call center, to replace the federal platform and call center, and provide electronic access to the health insurance exchange in this state by November 1, 2026.

But it’s not just Oregon: Check out what’s happening to another “O” state across the country:

Oklahoma Insurance Department Announces Transition to Health Insurance State-Based Exchange

OKLAHOMA CITY — The Oklahoma Insurance Department (OID) today announced that Oklahoma will transition from the federally facilitated HealthCare.gov platform to a State-based Exchange (SBE) for the 2028 Open Enrollment Period.

This transition, authorized by Oklahoma House Bill 1512, will enable Oklahoma to retain and reinvest revenue currently being sent to the federal government, enhance consumer experience, and spur local market growth. In addition to the transition, OID is planning to pursue a Section 1332 State Innovation Waiver to further strengthen affordability and market stability.

Consumers will continue to use HealthCare.gov to enroll in health plans for 2026 and 2027 coverage. Beginning in November 2027, consumers will be able to shop for and enroll in plans for the 2028 coverage year through Oklahoma’s State-based Exchange.

So there you have it: Oregon will move to an SBE this fall and Oklahoma will follow it a year later. At that point there will be 23 out of 51 states (including DC) operating their own exchanges...representing over 50% of the total U.S. population.

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Medicare & Medicaid Enrollment for November 2025:

Oddly, for all of the Trump regime’s messing with/purging of terabytes of public health data/information over the past year, one of the big fears which I had as a healthcare data wonk hasn’t come to fruition as of yet: The Centers for Medicare & Medicaid Services (CMS) has continued to put out what seem to be relatively accurate regular reports on enrollment data in ACA plans, Medicare, Medicaid & the Children’s Health Insurance Program (CHIP).

Last week, CMS published updated enrollment data for Medicare, adding November 2025 to the data archive.

Whether the data posted since January 20, 2025 is accurate or not, I can’t say for certain, but at least they’re updating it ... and so far, at least, I don’t see anything in their monthly reports which is setting off any obvious red flags.

In any event, according to the latest report, as of November 2025:

• Total Medicare beneficiaries are up to 69.73 million (up ~57K month over month)

• Traditional/FFM Medicare beneficiaries are at 34.10 million (up ~28K m/m)

• Medicare Advantage beneficiaries reached 35.63 million (up ~18K m/m)

• 12.08 million Medicare enrollees (17.3% of the total) were “Dual Eligibles”...that is, enrolled in both Medicare and Medicaid.

After crossing the 50% threshold two years ago, Medicare Advantage has now been, for good or for bad, the default option for Medicare enrollment ever since, with over 51% of all enrollees now utilizing Advantage plans.

In addition, the Trump Regime has also published the November 2025 update to the official Medicaid/CHIP enrollment data:

Medicaid and CHIP Enrollment

• In November 2025, 76.0 million individuals were enrolled in Medicaid and CHIP.

• 68.8 million individuals were enrolled in Medicaid, and 7.2 million individuals were enrolled in CHIP.

• 39.8 million adults were enrolled in Medicaid, and there were 36.2 million Medicaid child and CHIP enrollees.

Total Medicaid/CHIP enrollment in November 2025 dropped about 1.5% from October 2025, or by around 1.17 million people.

The all-time high enrollment watermark for Medicaid/CHIP was in April 2023, when it officially hit 94.1 million Americans (95.7 million when you include the U.S. territories).

It’s important to note that CMS actually has two different reports on Medicaid enrollment: The monthly Medicaid & CHIP Enrollment Trend Snapshot (referenced above) and the Medicaid Budget & Expenditure System (MBES).

The MBES numbers for U.S. territories stood at 1.44 million Medicaid enrollees as of June 2025. If you add those to the Trend Snapshot total for the 50 states +DC, it comes in at 77.47 million as of November 2025.

It’s also worth noting that ACA Medicaid Expansion enrollment specifically was 20.4 million as of June 2025 according to the MBES report, down around 3.6 million from the all-time high it reached in May 2023.

Finally, the summary report mentions in passing that ACA exchange enrollment in Qualified Health Plans (QHPs) was ~22.3 million in November, while Basic Health Plan (BHP) enrollment was still around 1.8 million.

The 22.6 million figure is noteworthy since it means net attrition of exchange enrollment as of October was only 7% vs. the ~24.3 million who selected exchange QHPs during the 2025 Open Enrollment Period.

Between December 2024 and November 2025, net Medicaid/CHIP enrollment has dropped by around 3.42 million, or 4.3%.

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And with that, I’ll see you again in two weeks!