2027 ACA Rate Filings Are In. Premiums Are Climbing Double Digits for the Second Straight Year.

The ACA marketplace peaked at 24 million enrollees in 2025. By the end of 2027, it could have fewer than 17 million.

The first wave of 2027 rate filings confirms why. Proposed premium increases range from 6.5% in Vermont to 22.4% in Washington, and last year’s nationwide median of 18% was already the highest in nearly a decade. This is the second straight year of double-digit increases across most states, landing on top of a 58% average jump in net premiums when enhanced subsidies expired.

Somewhere between seven and a dozen carriers have announced they won’t sell marketplace plans after 2026 — the two trackers following the exits don’t agree.

What’s Stacking Up

Three forces are compounding.

The enhanced premium tax credits that Congress extended from 2021 through 2025 expired at the end of last year. Those credits made marketplace coverage affordable for millions of people. Once they disappeared, healthier enrollees left first. They’re the most price-sensitive group, and the departure of lower-risk members is a pattern insurers in the 2027 filings cite repeatedly. Mass General Brigham Health Plan in Massachusetts pointed to the loss of “lower-risk members.” Community Health Plan of Washington said it “anticipates further market size reduction in 2027” with “higher healthcare needs, on average” among remaining enrollees.

Medical costs keep rising. PwC projects individual market cost trend at 8.5% for 2027. Insurers in their rate filings cite higher provider reimbursement rates, rising utilization, provider consolidation and specialty drug spending as the main drivers. Premera Blue Cross in Washington reported that limited competition and regional monopolies have reduced downward pricing pressure.

Federal policy changes are also pushing enrollment lower. CMS’s 2027 marketplace rule, finalized in May, adds paperwork requirements, increases out-of-pocket costs and loosens consumer protections. CMS itself projects the rule will reduce enrollment by 1.2 to 2 million people. A lawsuit challenging several of the rule’s provisions was filed June 3.

The Carriers Walking Away

The premium hikes come alongside a wave of insurer exits, and how big that wave is depends on which tracker you read. As of August 4, 2026, Louise Norris at healthinsurance.org counts at least a dozen insurers that will no longer offer marketplace plans after 2026, affecting several hundred thousand enrollees across multiple states. KFF’s participation tracker put the count at seven as of July 30, 2026, counting carriers leaving some or all of the states where they currently sell. Neither number is final — insurers have historically waited until the fall to announce marketplace exits.

Cigna is pulling out of 11 states, affecting about 369,000 enrollees. Baylor Scott and White is leaving Texas with about 100,000 affected. CareSource is exiting West Virginia, Ohio and Indiana (about 60,000 in Indiana, more than 28,000 in Ohio, and nearly 16,000 in West Virginia as of 2025). PacificSource is leaving Idaho, Montana and Oregon (60,000 combined). Providence Health Plan is leaving Oregon (nearly 36,000). Medica is dropping Iowa, Kansas and Oklahoma (about 13,000). Celtic/Ambetter is leaving Delaware and New Hampshire (nearly 12,000 in New Hampshire). Mending, the only DPC-integrated carrier on the exchanges, is ending all insurance operations across Maine (1,100) and Oklahoma (7,000). ConnectiCare is dropping off the Connecticut marketplace (3,719). Cox Health Plans is leaving the Missouri marketplace for off-exchange plans aimed at people with ICHRA benefits, and Sunshine State Health Plan is leaving Florida. Molina isn’t exiting outright but plans to shrink its individual market footprint from 14 states to six.

The reasons overlap. Cigna’s incoming CEO said there was “no clear path” to scale the company’s ACA business. Providence CEO Erik Wexler pointed to regulatory uncertainty and consolidation among larger competitors, saying that larger insurers “have the size and resources to operate more efficiently,” leaving Providence “in an untenable situation.” PacificSource cited unsustainable cost trends.

Georgia’s enrollment has already dropped 37%, from 1.5 million in early 2025 to 950,000 by April 2026. Washington lost 13% of its exchange enrollment despite state-funded subsidies. Across HealthCare.gov states, 21% of enrollees lost coverage for non-payment in early 2026.

The Risk Pool Feedback Loop

When premiums rise, healthier people leave first. That makes the remaining pool sicker on average. Sicker pools cost more to insure. Premiums rise again. More healthy people leave.

Insurers in the 2027 filings name this cycle explicitly. MVP Health Plan in Vermont said it hasn’t seen the “full impact” of expired subsidies yet, as it “continues to see retroactive coverage terminations for non-payment of premium.” Blue Cross Blue Shield of Vermont said the “large” morbidity adjustment it made was informed by analyzing the prior claims costs of people who dropped coverage in early 2026.

One filing puts a number on how severe the adjustment can get. MVP’s catastrophic plan carries a proposed 109% premium increase, driven by the expectation that broader eligibility rules in the 2027 federal rule will shift the catastrophic plan risk profile to match standard metal-level plans.

Where DPC Sits in This

The individual insurance market may shed 7 million enrollees within two years if CMS projections hold. Some will find employer-sponsored coverage. Some will go onto Medicaid. Some will go uninsured. And some will land at DPC practices.

DPC membership reached 1.4 million in 2025 with network presence in 49 states, according to the Hint Health 2026 trends report, which draws on data from more than 2,700 DPC clinicians. Membership grew 837% from 2017 to 2025. Employer-sponsored DPC now accounts for 60% of all memberships on Hint’s platform, and a separate Hint report, Employer Trends in Direct Primary Care 2025, counts more than 7,200 employer sponsors in its data. Monthly membership rates for employer-sponsored plans have stayed between $55 and $65 for five consecutive years.

A monthly DPC membership fee isn’t insurance. It doesn’t cover hospitalizations, surgeries or specialist care. But for primary care access, the economics compare favorably to a marketplace plan with a $9,450 deductible and a 22% annual premium increase. Wisconsin Public Radio reported in January that DPC practices across the state were fielding patient inquiries at unusual rates as premiums surged.

Mending’s trajectory is worth watching. Among the exiting carriers, it’s the only one whose exit is also a pivot toward DPC infrastructure. Mending launched Mending Access in January 2026, a platform helping self-funded employers and TPAs integrate DPC into their plans. It has already expanded DPC access to more than 100,000 covered lives and operates in 12 states, with plans to reach 25 or more by year-end.

What This Means

The ACA marketplace was built to make individual insurance accessible. For five years, enhanced subsidies made it work. Without those subsidies, the market is reverting to pre-2021 economics: shrinking enrollment, deteriorating risk pools and climbing premiums. The 2027 rate filings confirm this isn’t a one-year correction.

If you’re running a DPC practice, the pipeline of people looking for primary care outside the insurance system is growing because the insurance system is pricing them out. If you’re a physician considering DPC, the individual market contraction is context for why employer demand for DPC keeps growing. Employers watching their workforce lose affordable individual coverage have a reason to look at DPC as a primary care benefit. The Hint Health data shows they already are.