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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 that details this developing ACA risk pool morbidity 2026 trend. The analysis drew from data representing nearly 80% of individual market enrollment across 37 states.
Enrollment Declines Behind This ACA Risk Pool Morbidity 2026 Trend
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%.
Risk Score Increases Across Every Segment
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.
What This ACA Risk Pool Morbidity 2026 Data Shows About Enrollee Acuity
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.
Why This Distinction Matters
This combination, stable claims volume but rising condition complexity among those who do file claims, indicates the morbidity shift isn’t simply about more people getting sick, but rather about a changing mix where healthier enrollees are leaving the risk pool while higher-acuity members remain.
Medicaid Expansion States Show the Sharpest ACA Risk Pool Morbidity 2026 Shifts
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%.
Significant State-Level Variation
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.
Why This ACA Risk Pool Morbidity 2026 Picture May Understate the Full Trend
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.
The Connection to 2027 Premium Increases
Insurers offering coverage for 2027 have pitched a median rate increase of 15%, the second consecutive year of double-digit hikes, a pricing decision that directly reflects insurers’ own expectations about continued morbidity deterioration in the individual market risk pool.
What This ACA Risk Pool Morbidity 2026 Report Means Going Forward
With Wakely projecting full-year enrollment losses of 19% to 23% and expecting morbidity to continue worsening due to claims and coding lags, this ACA risk pool morbidity 2026 report suggests the individual market’s underlying risk profile has not yet fully stabilized even at the midpoint of the year. Given that Medicaid expansion states are experiencing both the sharpest enrollment declines and a dramatic shift toward bronze-tier coverage, insurers operating heavily in these states may face particularly acute pricing and risk-adjustment challenges heading into 2027.
What to Watch Going Forward
As claims data matures and coding lags resolve throughout the remainder of 2026, industry observers will likely watch whether Wakely’s projected 19% to 23% full-year enrollment decline holds, and whether the risk score increases seen so far accelerate as the report anticipates. Given the direct connection between this morbidity data and insurers’ already-announced 15% median premium increase proposals for 2027, this ACA risk pool morbidity 2026 trend will likely remain a central factor shaping marketplace pricing and insurer participation decisions through the upcoming plan year.
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