Covered California CMO speaks on ACA marketplace enrollment drops

Affordable Care Act (ACA) marketplace enrollment fell in 2026 for the first time in seven years.

As of February 2026, about 19.2 million people had ACA exchange plans, down from 22.1 million last year, according to federal data. Others stayed on the marketplace but switched to cheaper bronze-tier plans with higher out-of-pocket costs.

This shift has been attributed to changes such as premium spikes, the expiration of enhanced premium tax credits, and, according to the Trump administration, a crackdown on fraud.

States that run their own marketplaces and offer state-funded subsidies, like California, generally experienced lower enrollment drops than others, according to KFF, a nonprofit that conducts health policy research.

Still, though, in 2026, California’s official health insurance marketplace, Covered California, saw enrollment decrease by 7% to an estimated 1.8 million people in February 2026, down from 1.9+ million in February 2025, according to an April 16 report.

We talked to Monica Soni, chief medical officer at Covered California, about these enrollment changes and how they may impact the broader healthcare industry.

This interview has been lightly edited for length and clarity.

Covered California saw net enrollment drop in 2026. What do exit surveys indicate about where these people are going?

The folks that leave Covered California, many of them have an alternative source of coverage. They got a job, they’re going to employer-sponsored coverage, maybe a partner or spouse is able to cover them. But we do know that we have a percent of folks that leave that do just go uninsured. We don’t have those results yet, obviously, from what’s happening right now. I am extremely suspicious that we’re going to see a pretty substantial increase in the number of folks who were forced to go uninsured because of the economics.

Others are still enrolled through Covered California but switched from silver to bronze plans. What impact might that have on the medical system?

This was one of the—I mean, second only to going uninsured—one of the most concerning trends that I saw in our data.

We had people who were on silver or with chronic conditions, who have medical needs, who had to switch down, and we know what happens with that. The studies are clear, and our own data is clear. There’s more delays in care. There’s more delays in medication fills. There’s less primary care, less immunizations…and more emergency room visits because people end up crashing into care. As a primary care doctor, I’m extremely worried about this, and it’s yet another pressure point on our delivery system.

Are you afraid that enough healthy people will drop ACA coverage to cause a death spiral for the marketplace?

People aren’t wrong to be concerned about this. We cannot subsidize our way out of this. But I would put California in a class of its own.

This is the largest state-based marketplace, and a very stable one. Our risk pool has not traditionally changed so much that all of a sudden, it’s only unhealthy or complex patients that remain. That’s not the reality in California, given our size and scale.

Where I would worry is the delivery system. I mean, we do have smaller community practices, community clinics. They’re going to be losing Medi-Cal enrollees and Covered California enrollees, and they will shut down. I don’t think that is histrionics. I think that that is the truth of what is likely to happen.

On July 21, Covered California released a preliminary projection that the state’s premiums will increase again by a weighted average of 9.9% in 2027. The California Association of Health Plans, a trade organization, attributes the planned premium increases in part to rising hospital costs and specialty drugs like GLP-1s. Do you consider those big contributors?

One of the things that bothers me the most about healthcare is everyone points the finger to somebody else. And you can go back over years and see that we all are contributing. And I put myself, as a practicing physician, also in that category…But the biggest contributor is still really the cost of care within our delivery system. And yes, I think many health economists will point to pretty substantial prices within, particularly, our hospital systems.

Are there levers other than premium increases that you think insurance companies could pull to cut down costs?

Yes, yes, and yes, and we, at Covered California, are an active purchaser, so we are also always looking for levers as well as pushing our health plans to do more—particularly when we’re sitting in negotiations, but frankly, year-round. You know, I can’t do my job without the partnership of plans, and so I’m not here to demonize them or villainize them. But they are a certain type of organization. I think they have a historical set of levers, and I’m not sure that there is always both motivation and innovation around costs. We know that some of the tools used in the past, like prior authorization, cause a lot of friction across the delivery system, too.