The U.S. health insurance landscape has undergone major enrollment shifts in the individual and Medicaid markets since the onset of the COVID-19 pandemic, driven by federal pandemic policies and legislation. Federal regulatory and legislative changes appear likely to bring enrollment changes into both markets in 2026. Based on publicly available individual market and Medicaid data, this paper makes 10 key observations related to historical market trends and comments on potential impacts from recently enacted federal regulations and legislation.

Highlights

• Individual market growth: Gains in the individual market have been driven by subsidized marketplace enrollment, greatest in the 100-138% federal poverty level population.
• Medicaid market variation: Medicaid adult and enrollment changes relative to February 2020 have varied widely by state, and several recent federal proposals may result in notable shifts in enrollment levels.
• Expiration of enhanced premium subsidies: The Congressional Budget Office projects an overall decrease in individual market coverage of 3.5 million.
• Exchange-based changes: New rules related to income verification and repayment of excess premium subsidies may have greater effects on states using the federal exchange.
• Work and engagement requirements: Emerging policies targeting Medicaid expansion populations—such as community engagement or work requirements— are likely to add uncertainty and variation in Medicaid enrollment levels across states.