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On January 28, 2026, the Centers for Medicaid & Medicare Services (CMS)听released its second听鈥痮f 2026 Affordable Care Act (ACA) Marketplace Open Enrollment (OE) activity. While this update is not a final accounting of enrollment activity, it is likely to be the last OE federal data release for some time and offers an early look at how enrollment trends are shifting in the wake of expired enhanced premium tax credits and new eligibility standards under the 2025 budget reconciliation act (P.L. 119-21, OBBBA).听

In this article, 黑料不打烊 (黑料不打烊)听and Wakely, an 黑料不打烊 company,听highlight findings from their analysis of the 2026听OE activity and听compare听this activity听with 2025 data.听This analysis builds on the findings in听their January 2026 analysis听()听and will provide important context for the听2027 plan year.听

Overall Enrollment Trends听

CMS reports that 2026 plan selections decreased by 5 percent from 2025, with enrollment declining across both new and returning consumers. New sign-ups dropped by 14 percent and renewals fell by 3 percent (Table 1). State-based Marketplace (SBM) enrollment dipped modestly, though many SBMs were still enrolling consumers in late January.听

Table 1. Comparison of 2026 and 2025 Open Enrollment听

听	2026听	2025听	Net Change听
Total听	22,973,219听	24,166,491听	(1,193,272)听
New Consumers听	3,382,189听	3,938,907听	(556,718)听
Returning Consumers听	19,591,030听	20,227,584听	(636,554)听

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Variation Across State-Based and Federally Facilitated Marketplaces听

Enrollment patterns varied听substantially across听states.听

SBMs:听

• New Mexico听saw the听largest听year-over-year听increase听(14%), attributed to听state-funded subsidies听designed to听offset the loss of听enhanced premium tax credits (ePTCs).听
• Georgia听experienced a听14听percent decline,听the听steepest drop among听SBMs.听

Federally Facilitated Marketplace (FFM)听States:听

• Overall, FFM enrollment fell听5听percent.听
• Texas led听FFM states听with a听5听percent increase in听plan selections.听
• Ohio and North Carolina experienced听substantial enrollment declines,听20听percent听and听22听percent听respectively.听

What This Tells Us鈥攁nd听What听It听Doesn鈥檛听Tell Us听Yet听

FFM data are as of January 15, 2026,听and measure plan selections after the OE period ended.听Within the FFM, state-by-state enrollment activity varied significantly.听Some of this variation is surprising and not readily explainable from the available data and will be a focus of future听黑料不打烊听and Wakely analyses.听

The data include neither effectuated enrollment nor paid enrollment鈥攄ata which will be key to fully understanding 2026 enrollment trends and the impact of changing federal policies, including the听ePTC听expiration听and changing eligibility standards introduced in 2026 as the result of OBBBA.听

听suggest听significantly higher cancellation and disenrollment rates than in听previous years.听

SBMs are sharing that they expect听substantial affordability-driven voluntary and nonpayment terminations over the first half of 2026.听

Monitoring paid enrollments, attrition, and grace period dynamics, including retro-terminations, will be key to understanding market dynamics and 2027 pricing.听

Connect with Us听

黑料不打烊 and Wakley experts have considerable experience working with states, insurers, and federal policymakers with听jurisdiction听over the Marketplace. We work with these entities to inform, analyze, and听shape听federal policies and conduct impact analyses on pricing, enrollment, administration, and operations. 黑料不打烊 also provides strategic and project management support for the implementation of finalized policies.听

Please contact听Michael Cohen,听Taylor Gehrke, or听Zachary Sherman鈥痺ith questions, follow-up, or if you would like expert听assistance听exploring any of the issues discussed in this post.

On February 3, 2026, Congress finalized federal funding for fiscal year (FY) 2026, with the House passing the Consolidated Appropriations Act (CAA), 2026, with a vote of 217-214, following Senate approval last week. The president signed the CAA () shortly thereafter. The law provides full-year appropriations for the Departments of Health and Human Services (HHS), Housing and Urban Development, Labor, and several other departments.听

This year鈥檚 HHS funding bill is notable not only for what it includes, but also for what it omits. It restores or maintains funding for key public health and research agencies previously proposed for elimination in the president鈥檚 FY 2026 , extends several healthcare programs, and contains a significant package of pharmacy benefit manager (PBM) reforms. All of this activity comes as the Administration 听new grant programs and policy efforts听related to听its听signature priorities.听

In this article, we review the major funding and policies approved in the HHS spending bill. We also address key considerations for healthcare organizations as they anticipate downstream funding and policy developments and develop advocacy initiatives for federal FY 2027 bills.听

HHS Funding Levels and Direction听

The bill provides $116.8 billion for HHS, an increase of $210 million over FY 2025, and rejects large-scale structural reorganizations proposed in the president鈥檚 FY 2026 budget. This provision preserves funding for the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), Health Resources & Services Administration (HRSA), and the Substance Abuse and Mental Health Services Administration (SAMHSA)听

Table 1. HHS Agency听Funding听Highlights, FY 2026听

Agency听听	FY 2026 Funding听听	(+/-) Compared听with听FY 2025听
Administration for Strategic Preparedness and Response (ASPR)听	$3.7听billion听	+$58听million听听
CDC听	$9.2 billion听	level funding听
Centers for Medicare听&听Medicaid Services (CMS),听administrative expenses听only听听	$3.7 billion听	level funding听听
听HRSA听	$8.9 billion听	+$415听million听听
National Institutes of Health (NIH)听	$48.7 billion听听	+$929听million听听
SAMHSA听	$7.4 billion听听	+$65听million听听

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The bill also extends mandatory funding for community health centers, special diabetes programs, the National Health Service Corps, and Teaching Health听Center听Graduate Medical Education.听

PBM Reforms in the Package听

In one closely watched area of federal policymaking, the FY 2026 package includes a substantial set of PBM-related reforms that听largely mirror听the bipartisan package negotiated听but not enacted听in December 2024. These reforms have implications across Medicare Part D, commercial insurance, and employer-sponsored plans.听

The legislation听contains听the following听PBM reforms:听

• Prohibits PBMs from deriving听remuneration听linked to drug prices for听Medicare-covered Part D drugs听
• Restricts spread pricing in Medicaid,听eliminating听a major driver of PBM revenue听
• Requires contractual transparency, mandating that PBMs clearly define pricing terms in agreements with Part D plan sponsors听
• Adds new PBM reporting obligations, including drug price reporting and rebate disclosures听
• Requires 100听percent听passthrough of rebates in ERISA-regulated plans for new, renewed, or extended contracts beginning听30 months听after enactment听
• Expands audit rights for plan sponsors听
• Codifies the 鈥渁ny willing pharmacy鈥� requirement for Medicare plan sponsors听

These provisions position 2026 as a consequential year for PBM regulation, increasing transparency, strengthening plan leverage, and heightening HHS oversight.听

Healthcare Extenders and Program Reauthorizations听

The bill includes a broad set of Medicaid, Medicare, and public health program extenders, affecting providers, patients, states, and managed care plans.听

Medicaid听

• Postpones reductions听in the听Disproportionate Share Hospital (DSH)听allotments听until FY 2028听
• Changes听the听DSH cap calculation听to听broaden which patient costs count toward Medicaid shortfall听
• Requires states to听develop and implement a process to听allow certain out-of-state pediatric providers to deliver services without听additional听screening for three years听
• Removes age limits on Medicaid鈥檚 Ticket to Work program, allowing adults older than age听65 to听participate听and requires state compliance by January 1, 2028听
• Establishes new maternity care reporting requirements听for rural hospitals, with dedicated federal funding听for hospitals听and states to听comply with听the reporting听

Medicare听

Congress extends several key programs and payment provisions, including:听

• Telehealth flexibilities through December 31, 2027听
• Incentive payments for participation in eligible alternative payment models through payment year 2028 (for performance year 2026) and applies an adjustment amount of 3.1 percent for 2028听
• Acute Hospital Care at Home waivers through 2030听
• Low-volume and Medicare-dependent hospital payment adjustments听
• The听1.0 work geographic practice cost index floor used in the calculation of payments under the Medicare physician fee schedule through December 31, 2026听
• Add-on payments for ambulance services听
• Continuation of Part D coverage for certain antivirals and modifications to hospice payment caps听

Behavioral Health Policy听

The appropriations bill听was听finalized听as the听administration听听new funding and policy initiatives听to听support behavioral health, crisis services, workforce expansion, and youth mental health鈥攅fforts mirrored in SAMHSA鈥檚 increased appropriations.听

SAMHSA鈥檚听$7.4 billion听budget听includes:听

• $1.6 billion听for State Opioid Response grants听
• $1.01 billion听for the Mental Health Block Grant听
• $535 million for the 988 Suicide and Crisis Lifeline听

Considerations for Stakeholders听

Federal听funding and听policy developments听affect听state budget dynamics as many states are now releasing 2026鈥�2027 budget proposals听as well as the听operational and growth plans of healthcare organizations and partners.听

A few key听takeaways听from the听FY 2026 funding bill听include:听

• Federal appropriations signal听congressional and听administration priorities and have听downstream听impact on upcoming rounds of grant cycles, including听SAMSHA and HRSA听awards.听
• The approved funding and certain policy extensions provide operational stability and reduce near-term fiscal pressure, such as the further delay of Medicaid DSH cuts. The extra time will allow healthcare entities to prepare for future reductions and plan for financial sustainability.听
• Agency and program funding emphasize oversight, program integrity, and听compliance. In addition,听fraud and program integrity听priorities are听woven into听certain听new听policies听and program听extensions,听including听PBM reforms, flexibility for pediatric care across state borders,听and rural maternity cost reporting requirements,听among others.听

Connect with Us听

If you would like deeper analysis or state and stakeholder-specific effects, 黑料不打烊鈥檚听policy experts听are available to听assist.听