Georgia lost 28 percent of its effectuated April marketplace enrollment year over year per an analysis by Charles Gaba, a healthcare policy analyst and blogger who specializes in the ACA, reported by Julie Appleby for KFF Health News on May 19, 2026 (Appleby, KFF Health News, May 19, 2026). It is the sharpest drop in people paying premiums Appleby flagged, based on what she characterized verbatim as "limited data" from a handful of state-based marketplaces and Charles Gaba's synthesis of available CMS effectuated-enrollment data.
The figure measures one specific thing. Effectuated enrollment is the federal definition for a person who selected a marketplace plan, paid the first premium, and remained active in coverage on the last day of the month. Charles Gaba's analysis compares April 2025 effectuated enrollment in Georgia against April 2026 effectuated enrollment in Georgia. Roughly 21 percent of people using the federal ACA marketplace, across 30 states, failed to pay their share of January 2026 premiums per CMS data Appleby cited. Georgia's 28 percent drop in April effectuated enrollment over a 12-month window is, in Appleby's reporting, the deepest single-state figure.
What 28 percent measures, and how it differs from the 37 percent in the earlier reporting
Two metrics describe Georgia's marketplace from different angles, and they do not interchange.
The 28 percent figure (Charles Gaba via KFF Health News, May 19, 2026) measures effectuated April marketplace enrollment year over year, April 2025 to April 2026. It captures one annual attrition cycle on the same April-to-April denominator.
The 37 percent figure (Georgia Recorder, April 20, 2026) measures marketplace plan-selection enrollment over a 16-month span, January 2025 to April 2026, from approximately 1.5 million enrollees to approximately 950,000. It captures a longer attrition window starting from a higher denominator (the full Open Enrollment Period plan-selection count, not the subset who paid the first premium). The 37 percent appeared in our May 22 piece on the One Big Beautiful Bill Act's enhanced premium tax credit rollback.
Both figures are true. Both are sourced. They describe related but distinct phenomena and the underlying driver, the December 31, 2025 expiration of the enhanced premium tax credits the American Rescue Plan introduced in 2021 and the Inflation Reduction Act extended through 2025, is the same in both cases. The One Big Beautiful Bill Act reconciliation package did not renew them. Subsidies reverted to pre-2021 amounts for the 2026 plan year.
Why the deepest drop landed in Georgia
The four Southern non-expansion states carry the largest share of Americans who depend on the marketplace as the only available subsidized coverage path. Texas, Florida, Georgia, and the other Southern non-expansion states hold 97 percent of the approximately 1.5 million Americans currently in the Medicaid coverage gap; Texas accounts for 42 percent of the gap population, Florida for 19 percent, and Georgia for 14 percent, per a February 25, 2025 KFF brief by Sammy Cervantes, Clea Bell, Jennifer Tolbert, and Anthony Damico. Six in ten people in the coverage gap are people of color per the same brief. The Black uninsured rate under age 65 stood at 10 percent in 2023, compared to 7 percent for non-Hispanic White Americans, per a December 16, 2025 KFF chartbook by Nambi Ndugga, Latoya Hill, Alisha Rao, Akash Pillai, and Samantha Artiga.
Approximately 3 million Black Americans made plan selections on HealthCare.gov during the 2024 open enrollment period per HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE 2024). ASPE estimates race and ethnicity by combining self-reported data with an imputation method that uses geocoded address, surname, and other characteristics for enrollees who do not self-report. Note: the 3-million figure covers HealthCare.gov enrollment in the 32 states that use the federal marketplace; it does not include state-based marketplace enrollment in California, New York, Washington, or the 15 other states that run their own exchanges.
Charles Gaba's reading, per the KFF Health News piece, is that Georgia "could be fairly representative" of other unprotected states. Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University, told KFF Health News the underlying mechanic is unambiguous: "In economic theory, no matter whether one is left, right, or center, it's a simple fact that when you raise prices of something, fewer people will buy it." Ellen Montz, managing director with the Manatt Health consultancy and a former Biden administration CMS official who helped oversee the ACA, told KFF Health News that "we can't yet quantify how much worse it will be than in previous years, but it will absolutely be worse because of the sticker shock," and added that the enrollees dropping coverage "are real people with real consequences."
The 2027 underwriting-pool composition shift
The mechanism that drives next year's rates runs in three steps and Appleby's named experts walk it without softening.
Step one is the price-driven dropout. Premium payments rose sharply in January 2026 for many enrollees per the May 19, 2026 KFF issue brief by Matt McGough, Jared Ortaliza, Justin Lo, and Cynthia Cox. The KFF projection is 17.5 million in marketplace coverage for the full 2026 plan year, down from 22.3 million in 2025; the Congressional Budget Office trajectory takes the projection to 15.4 million by 2034 if no restoration occurs.
Step two is the risk-pool composition shift. When the lowest-income, healthiest-on-paper enrollees drop coverage first because premiums rose, the remaining pool skews older and sicker. Louise Norris, a health policy analyst for healthinsurance.org, told KFF Health News that "we know for sure that the individual market has gotten smaller and almost certainly sicker." Norris described the actuarial environment as "definitely a challenging year to be an actuary."
Step three is the 2027 rate filings, which insurers submit on rolling deadlines through state regulators between summer and early fall 2026. Michelle Anderson, director at the Wakely Consulting Group, told KFF Health News that "it would not surprise me if there were some double-digit increases." Wakely's actuarial analysis is one of the load-bearing prospective sources in Appleby's reporting; Charles Gaba's healthcare policy tracker is the other.
The structural-equity arithmetic is the part the press coverage to date does not run. The deepest single-state effectuated-enrollment drop KFF Health News flagged is in the state where the Black-Southerner-coverage-dependence concentration is highest. KFF Health News does not break out Georgia's 28 percent decline by race. None of the sources we located today disaggregate the April-2025-to-April-2026 Georgia attrition by race. The federal data layer makes the structural-overlay inference straightforward without inventing the missing cell: Black Americans hold disproportionate marketplace coverage in Southern non-expansion states, Georgia carries 14 percent of the national coverage-gap population, and when enhanced premium tax credits expired without a state-level backfill, the population most exposed to losing marketplace coverage was the population least likely to have an alternative pathway.
State-level action can backfill federal-policy erosion. None of the four Southern non-expansion states has done it.
A 2026 JAMA research letter by Olurotimi Kukoyi and colleagues at the University of North Carolina at Chapel Hill, the Common Health Coalition, the Institute for Healthcare Delivery Design, and Duke University analyzed US state actions in 2025 that strengthened or weakened COVID-19 vaccination infrastructure (Kukoyi et al., JAMA 2026, PMID 42008283). The methodological frame is the relevant import for ACA coverage. When federal infrastructure erodes, state actions can backfill or accelerate the erosion. The four Southern non-expansion states with the deepest 2026 marketplace exposure (Texas, Florida, Georgia, and the bloc of non-expansion neighbors) have not enacted state-level marketplace-stabilization programs comparable to Maryland's state reinsurance program and Prescription Drug Affordability Board or to New York's Essential Plan.
Maryland's relative cushion is documented in the comparative state data. Maryland did not appear among the deepest 2026 marketplace declines in either the McGough KFF brief (which reported the largest plan-selection drops in North Carolina, Ohio, West Virginia, Indiana, Delaware, and Arizona) or the Appleby effectuated-enrollment piece. State-level cost-containment and rate-stabilization tools, when they exist, moderate the federal-rollback impact. Where they do not exist, the impact concentrates.
What you can do
If you have lost coverage because you could not afford the higher 2026 premium, your nearest no-cost intake point is healthcare.gov for federal-marketplace states (Georgia is in this group) or your state-based marketplace site for the 19 states that operate their own. Loss of enrollment because of premium nonpayment can in many cases qualify you for a Special Enrollment Period; the operative test is the cause of the loss, not the calendar quarter. Federally Qualified Health Centers and county health departments offer charity-care intake for the period between coverage loss and the next plan year; the HRSA finder is at findahealthcenter.hrsa.gov.
If you are still covered and considering dropping coverage because the 2026 premium feels unreachable, the formal step that preserves the option to come back in is a request for plan downgrade through your marketplace account before the premium nonpayment cascade triggers automatic termination. The marketplace plan-finder tools at healthcare.gov or your state-based marketplace let you sort by 2026 premium against 2026 deductible. Bronze plans with health savings account compatibility are the lowest-monthly-premium tier still inside the marketplace's actuarial-value floor; the trade is a higher deductible at point of care.
If you are watching the policy track for 2027, the next operative decision points are the state insurance commissioner rate-filing windows that open between summer and early fall 2026 and the federal reconciliation or appropriations cycle that could revisit the enhanced premium tax credit question before the 2027 plan year. Public-comment opportunities on insurer rate filings vary by state; your state insurance commissioner's office is the access point. The National Association of Insurance Commissioners maintains a state regulator directory at naic.org/state-insurance-departments.
Citations
- Appleby J. "Eroding ACA Enrollment Portends Higher Insurance Rates." KFF Health News. May 19, 2026. https://kffhealthnews.org/insurance/eroding-aca-enrollment-higher-insurance-rates/
- McGough M, Ortaliza J, Lo J, Cox C. "What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles." KFF Issue Brief. May 19, 2026. https://www.kff.org/affordable-care-act/issue-brief/what-we-know-so-far-about-2026-aca-marketplace-enrollment-premiums-and-deductibles/
- Cervantes S, Bell C, Tolbert J, Damico A. "How Many Uninsured Are in the Coverage Gap and How Many Could Be Eligible if All States Adopted the Medicaid Expansion?" KFF Issue Brief. February 25, 2025. https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/
- Ndugga N, Hill L, Rao A, Pillai A, Artiga S. "Key Data on Health and Health Care by Race and Ethnicity." KFF. December 16, 2025. https://www.kff.org/racial-equity-and-health-policy/issue-brief/key-data-on-health-and-health-care-by-race-and-ethnicity/
- HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE). "HealthCare.gov Plan Selections by Race and Ethnicity, 2015-2024." October 1, 2024. https://aspe.hhs.gov/reports/healthcaregov-plan-selections-race-ethnicity-2015-2024
- Kukoyi OM, Wang VS, Yao K, et al. "US State Actions Related to COVID-19 Vaccination Infrastructure and Access Amid Federal Shifts." JAMA. April 20, 2026. PMID 42008283. https://pubmed.ncbi.nlm.nih.gov/42008283/
- HRSA Find a Health Center. https://findahealthcenter.hrsa.gov/
- National Association of Insurance Commissioners. State Insurance Departments. https://content.naic.org/state-insurance-departments
