New York: Effectuated enrollment down ~7% so far this year; will likely skyrocket this summer, but don't get too happy...

New York, like 8 of the other 9 states I've run 2026 effectuated enrollment analysis of so far, once again has unique circumstances which make it an outlier compared to most states when it comes to analyzing ACA exchange enrollment and comprehensiveness of coverage.

This is no coincidence for a simple reason: The only ACA exchanges which provide monthly effectuated enrollment data at all are the 21 which are hosted on a state-based exchange platform...which also tend to be states which offer their own supplemental financial assistance or other special healthcare coverage programs specifically targeted towards the ACA individual market (as an aside, 16 of those 21 states are Democratic-leaning, with the remaining 5 considered either swing states (Georgia, Nevada, Pennsylvania) or red states (Idaho, Kentucky).

The biggest distinction here is that, like DC, Minnesota and Oregon, New York has had a Basic Health Plan (BHP) program in place for the past decade. As my colleague Louise Norris explains:

Under the ACA, most states have expanded Medicaid to people with income up to 138 percent of the poverty level. But people with incomes very close to the Medicaid eligibility cutoff frequently experience changes in income that result in switching from Medicaid to ACA’s qualified health plans (QHPs) and back. This “churning” creates fluctuating healthcare costs and premiums, and increased administrative work for the insureds, the QHP carriers and Medicaid programs.

The out-of-pocket differences between Medicaid and QHPs are significant, even for people with incomes just above the Medicaid eligibility threshold who qualify for cost-sharing subsidies.

The Basic Health Program (BHP) – section 1331 of the ACA — was envisioned as a solution, although most states did not establish a BHP. Under the ACA (aka Obamacare), states have the option to create a Basic Health Program for people with incomes a little above the upper limit for Medicaid eligibility, and for legal immigrants who aren’t eligible for Medicaid because of the five-year waiting period.

In short, if you earn up to 138% FPL, you enroll in Medicaid; from 138 - 200% FPL, you enroll in a Basic Health Plan policy (BHP); at 200% FPL or higher, you enroll in a Qualified Health Plan policy (QHP).

Federal funding for BHP programs is supposed to be equal to 95% of the total amount of advance premium tax credits (APTC) and cost sharing reduction (CSR) assistance that the enrollees would otherwise have been eligible for had they otherwise enrolled in a QHP using the ACA exchange.

Of course, the state itself can also throw in additional funding to make the BHP plans more generous if they wish...which is a key point to keep in mind. The coverage has to be at least as affordable and at least as good as a benchmark silver plan with Cost-sharing reduction benefits applied.

The main point here is that nationally, around 2/3 of all ACA exchange enrollees earn less than 200% of the Federal Poverty Level (FPL). In states with BHP programs, exchange enrollment under 200% FPL makes up less than 3% of the total...because practically everyone who earns below 200% FPL is enrolled in either Medicaid (up to 138% FPL) or the state's BHP program (138 - 200% FPL) instead.

In New York specifically, in fact, it goes one step further...at least for the moment. A couple of years back, the state dramatically expanded their BHP program to extend even further up the income level to 250% FPL:

On March 1, 2024, the U.S. Department of Health and Human Services (HHS) and U.S. Department of Treasury approved New York's Section 1332 State Innovation Waiver application to expand the Essential Plan. Section 1332 State Innovation Waivers allow states to pursue innovative strategies for providing residents with access to high quality, affordable health insurance. The waiver was approved for five years, from 2024 through 2028.

...Key Components of the Waiver

This approved State Innovation waiver expands health insurance and covers health-related social needs, improving health care and advancing health equity. The waiver includes the following key components:

Extending Affordable Health Insurance to Over 100,000 New Yorkers – The Essential Plan will be expanded to New Yorkers with incomes between 200 and 250 percent of the FPL, making the high quality, affordable program available to over 100,000 additional New Yorkers.

Technically speaking, New York didn't expand the existing BHP program; instead, they received federal approval to replace the official BHP program with a new, more robust program which just happens to be nearly identical to an official BHP...except that it includes a wider income range (along with some other smaller enhancements).

As a result, in New York State, practically no one below 250% FPL is enrolled in an exchange QHP at the moment, which obviously has a huge impact on other demographics like metal level choices/etc. A whopping ~1.7 MILLION New Yorkers are currently enrolled in the state's BHP, branded as "The Essential Plan," or around 8.5x as many as those enrolled in exchange QHPs.

With that in mind, here's what Open Enrollment Period (OEP) plan selections look like for the year so far; everything up through 2024 is via official CMS Public Use File data; 2025 and 2026 data is via official NY State of Health enrollment reports:

Official OEP plan selections were around 5% lower for 2026 than they were in 2025, with nearly all of the drop-off coming from households earning more than 400% FPL (which makes sense, since there was almost no one under 250% and the 250 - 400% income range is the least impacted by the expiration of the enhanced federal tax credits this year:

As you can see, enrollment over 400% FPL dropped by ~45,000 people...while those with "unknown/other" incomes increased by ~39,000, which basically just means that most of the ~45,000 are still enrolled, they just earn well over 400% FPL and know they no longer qualify for tax credits so didn't bother even entering a projected income this year at all.

SINCE the end of Open Enrollment in January, however, effectuated enrollment, which was initially only 3.3% lower than last year, has dropped off at an increasing rate: As of May, it's down 8.7% vs May 2025. That's a monthly average around 7% lower than last year so far, or roughly 14,500 fewer people with coverage than last year.

Here's what this looks like visually. You'll notice two important differences between New York and the other states in this series: First, actual effectuated enrollment over the course of 2019 was much higher than it was in 2025. This is because 2025 includes the expansion of the BHP program--the ~25,000 or so gap is due to people in the 200 - 250% FPL range moving from exchange QHPs to BHP coverage.

The second difference is the big red asterisk & disclaimer in the middle...which I'll explain below the graph:

So what's that all about? Well, as I said above, for the past few years, New York has had a revamped/expanded BHP program which offers coverage to residents who earn up to 250% FPL instead of the normal 200% FPL.

Unfortunately, due to Congressional Republicans passing the so-called "One Big Beautiful Bill Act" (aka H.R.1 or the #BigUglyBill), New York is being forced to scrap the expanded program and revert back to the original 200% FPL-capped BHP program instead:

ALBANY, N.Y. (March 23, 2026) - The New York State Department of Health provided an update following federal approval from the Centers for Medicare & Medicaid Services (CMS) of the State’s request to terminate its Section 1332 State Innovation Waiver and return to Basic Health Program (BHP) authority.

The transition preserves Essential Plan coverage for approximately 1.3 million New Yorkers with incomes below 200 percent of the federal poverty level.

...As a result of federal policy changes, most of the approximately 450,000 New Yorkers currently enrolled through the Essential Plan benefits will become eligible for Qualified Health Plans in the individual marketplace beginning July 1, 2026, where they may face higher premiums, deductibles and out-of-pocket costs.

You may be wondering why the funding loss & reversion to the original BHP scope is expected to kick ~450,000 enrollees out of the program given that the expansion of the program only added perhaps ~100,000 or so at its peak. That's where the other shoe drops:

The loss of coverage for these low-income New Yorkers is a direct result of H.R. 1 (Public Law No. 119-21), the federal budget legislation championed by Congressional Republicans that eliminated funding for the expanded Essential Plan.

...H.R. 1, signed into federal law in July 2025, eliminated premium tax credit eligibility for most lawfully present immigrants that made the expanded Essential Plan financially viable for New York State. With half of the program funding eliminated, the State requested CMS approval to terminate the 1332 waiver, effective July 1, 2026. CMS has approved that request.

Again: Until this year, documented low-income immigrants who aren't eligible for Medicaid due to having lived in the U.S. for less than 5 years were eligible for federal ACA tax credits...which is also what forms the basis of BHP program funding. The Trump Regime changed the definition of "eligible immigrants" so that this population is no longer eligible for ACA subsidies, which in turn means they're also no longer eligible for BHP funding.

New York has an unusually high percentage of documented (ie, legally-present) recent immigrants, which, combined with how BHP programs are funded, makes this a crippling blow to the expanded program.

Starting July 1st, all ~450,000 of these folks--over 25% of all enrollees--will be kicked off the Essential Plan program.

The silver lining is that most of them will be eligible for standard subsidized ACA exchange coverage instead. While this is much better than not having any options, it's still gonna be ugly:

For the 450,000 affected New Yorkers, the transition from Essential Plan to Qualified Health Plan coverage represents a significant change. While Essential Plan enrollees currently pay $0 in premiums and face minimal cost-sharing, Qualified Health Plans may include monthly premiums and higher deductibles. Even with available federal tax credits, enrollees will incur monthly premiums and can face deductibles of thousands of dollars before coverage kicks in. This comes at a moment when New Yorkers are already navigating household budget pressures that have stretched family finances to the limit. The state cannot make up for these devastating cuts but is working with insurers to ensure that anyone moving from the Essential Plan to a Qualified Health Plan mid-year will see their deductible cut in half.

The affordability burden is compounded by the expiration at the end of 2025 of enhanced premium tax credits that were first established under the American Rescue Plan Act of 2021 – credits that Congressional Republicans allowed to expire. Those credits significantly lowered QHP premiums for moderate and low-income consumers; without them, costs in the Qualified Health Plan market are nearly 40% higher than they would otherwise be — leaving the 450,000 transitioning New Yorkers in an even more financially precarious position.

It gets even worse: In addition to expanding the Essential Plan program out to enrollees earning 250% FPL, the 1332 Waiver also included some other important affordability improvements to New York's ACA program:

The State is proposing to implement three new initiatives on the Exchange: 1) Provision of a Cost Sharing Reduction (CSR) wrap for Individuals 250 – 400% of the FPL; 2) Provision of a CSR wrap for individuals seeking services to manage their Diabetes; and 3) Provision of a CSR wrap for individuals who are pregnant or postpartum.

 

...The State is proposing to provide a CSR wrap to individuals with incomes up to 350% of FPL who are not Essential Plan eligible, by expanding eligibility for existing Silver CSR 87 plans to consumers eligible for Advance Premium Tax Credit (APTC) with incomes up to 350% of the FPL and eligibility for existing Silver CSR 73 plans to consumers with incomes above 350% up to 400% of the FPL. These changes are being proposed for several reasons. Cost sharing reductions will help increase access to care, address consumer complaints about high out-of-pocket costs, and reduce provider uncompensated care.

In other words, the ~64,000 (?) ACA exchange enrollees earning between 250 - 350% FPL have been getting significant additional financial help for out of pocket costs which they otherwise wouldn't have been eligible for, while the ~25,000 or so earning 350 - 400% FPL have been receiving nominal assistance as well.

In addition...

The State is proposing to reduce cost-sharing for non-hospital-based diabetes-related services, supplies and prescription drugs, for all QHP consumers in all metal levels. Consumers will be able to remain in the plan of their choice to receive this cost sharing reduction. There will be no change to plan premiums, benefits, or actuarial values.

Consumers will have $0 out-of-pocket costs for diabetes-related services.

...The State is proposing to reduce cost-sharing for outpatient pregnancy and postpartum care, inclusive of mental health services, for all QHP members in all metal levels. Consumers will be able to remain in the plan of their choice to receive this cost sharing reduction. There will be no change to plan premiums, benefits, or actuarial values.

Currently, there is limited cost-sharing permitted for maternal health services in QHPs. The United States Preventive Services Task Force (USPSTF) broadly defines preventive pregnancy services to include office visits, prenatal vitamins, breast pumps, pre-eclampsia, and supplies.

Examples of maternal health services that do still have cost-sharing include prescription drugs and postpartum mental health benefits.

Consumers will have $0 out-of-pocket costs for all outpatient covered services, supplies, and prescription drugs during pregnancy and postpartum.

According to this official 2026 Open Enrollment Period report from NY State of Health, around 42,000 exchange enrollees earning 250 - 400% FPL received special CSR assistance last year, as did around 26,000 with diabetes and 3,700 with pregnancy/postpartum claims (in some cases these may overlap with each other).

I'm assuming that all of these enhancements are also being scrapped as well, at least according to how this overview of the 1332 Waiver itself is worded:

Overview of Draft 1332 Waiver Amendment

...New York intends to use passthrough funding to implement three cost sharing reduction (CSR) subsidies for consumers 1) with incomes up to 400% of the FPL, 2) consumers receiving diabetes services, and 3) consumers receiving pregnancy and postpartum care services beginning in 2025.​

The net result of all of this is that ACA exchange enrollment will probably see a significant spike this summer in New York specifically as hundreds of thousands of BHP enrollees are kicked off that program and have to scramble for exchange coverage instead via a Special Enrollment Period. I won't be surprised if exchange enrollment doubles or even potentially even triples in NY in July/August. However, that will hardly be something to celebrate given the circumstances...especially since it looks like there's already a lot of confusion & miscommunication about the transition. From a friend of mine:

I just saw someone on Reddit this week saying that NY has sent out notifications to members in the 200-250% range, but that NYSOH hasn't been updated to show those folks what their subsidy will be, and was still just showing that they're eligible for the EP. I haven't tinkered with the quoting tool to see for myself, but oof. If you're in that boat and trying to figure out what's going on, that's not ideal.

(sigh) In any event, here's where things stand so far...

• California: OEP down 2.6%; February effectuations down 8.5%
• Colorado: OEP down 1.9%; March effectuations down 6.1%
• Georgia: OEP down 12.3%; April effectuations down 28.1%
• Maryland: OEP up 3.4%; April effectuations down 6.3%
• Massachusetts: OEP up 3.7%; April effectuations down 4.3%
• Minnesota: OEP down 8.1%; February effectuations down 8.6%
• New Jersey: OEP down 0.8%; April effectuations down 11.6%
• New Mexico: OEP up 18.1%; May effectuations up 5.6%
• New York: OEP down 4.9%; May effectuations down 8.7%
• Washington: OEP down 5.9%; February effectuations down 15.7%

In terms of year over year average monthly effectuated enrollment as of the months of the latest data:

• California: Down ~110,000
• Colorado: Down ~13,400
• Georgia: Down ~370,000
• Maryland: Up ~7,000
• Massachusetts: Up ~1,600
• Minnesota: Down ~10,000
• New Jersey: Down ~57,000
• New York: Down ~14,500
• New Mexico: Up ~7,200
• Washington: Down ~33,000
• Total across 10 states: Down at least ~595,000

I'm still working on effectuated data for the remaining states which operate their own ACA exchanges: Connecticut, DC, Idaho, Illinois, Kentucky, Maine, Nevada, Pennsylvania, Rhode Island, Vermont & Virginia...and again, the official effectuated data for every state for the first part of the year likely won't be released by CMS until sometime in July.

Stay tuned...