Texas entered 2026 with a record 4.17 million Health Insurance Marketplace plan selections. By February, however, only approximately 3.28 million Texans had active coverage, representing 146,000 fewer enrollees than the previous year and nearly 895,000 fewer than those who initially selected a plan. The gap between choosing a plan and activating it grew from approximately 543,000 Texans in 2025 to 895,000 in 2026. Put differently, about 86% of 2025 selections became active coverage, compared with only 79% this year. 

Texas’s active Marketplace enrollment declined by approximately 4%, substantially less than the 12% national decline. However, only 79% of plan selections resulted in active coverage, giving Texas the largest gap between plan selection and active coverage among states with comparable CMS data.

The 895,000-person difference should not be interpreted as an equivalent increase in the number of uninsured Texans. Some individuals likely obtained coverage through other sources, canceled an automatic renewal, or never paid the required premium. Even so, the historically large gap signals that open-enrollment totals alone do not fully capture whether Texans can activate and sustain coverage.

A shift in what Texans are purchasing

The movement across coverage tiers adds another dimension. Bronze plans accounted for approximately 31% of Texas selections in 2026, up from 18% in 2025.  Bronze plans generally offer lower monthly premiums, but higher deductibles and cost sharing. Meanwhile, Gold plans became the most popular tier in Texas, as state policy and enhanced federal subsidies narrowed the premium difference between plan tiers, making Gold plans more affordable for many consumers.

This creates a divided picture. Some Texans found greater value in more comprehensive coverage, while others appear to have prioritized the lowest available monthly premium. Data on active coverage by metal tiers is not yet available, so it is unclear whether Bronze, Silver, or Gold enrollees were more likely to never activate coverage or to discontinue it after enrollment.

A rural warning within the statewide numbers

The CMS data from February do not indicate where the decline occurred. Earlier plan selection data, however, point to a clear geographic divide. Rural Texas selections fell by approximately 3.2% from 2025, while urban selections increased by 6.5%. In other words, all of Texas’s enrollment growth, before premiums were paid, occurred in urban communities.

An Episcopal Health Foundation commissioned analysis found that more than one in four (28%) residents in rural Starr County had Marketplace coverage in 2025. In East Texas, approximately 18% of residents in Polk and San Jacinto counties were enrolled. In these communities, Marketplace coverage represents a meaningful share of the total population, not just a small segment of residents, making changes in enrollment more consequential for local healthcare systems.

Based on available data, it is difficult to determine if these counties experienced disproportionate losses. But where Marketplace plans cover a substantial share of the population, even a modest decline can affect more than individual households. It can interrupt ongoing care and reduce an important source of payment for local physicians, clinics, and hospitals, particularly in communities with few clinicians and limited financial margins.

The 2027 enrollment period may be a more difficult test

The next enrollment period will be shorter, running from November 1 through December 15. Texans will have less time to compare premiums, deductibles, and provider networks, replace plans that are no longer available, and resolve application problems.

Some applicants may also encounter additional verification requirements. Beginning in 2027, the federal Marketplace will require further income documentation when federal data indicate household income below 100% of the federal poverty level or when tax data are unavailable. It will also conduct pre-enrollment verification for at least 75% of new enrollments made through Special Enrollment Periods. These policies are intended to strengthen eligibility and program integrity, but they also place greater importance on clear communication and timely assistance for eligible consumers with variable income or incomplete documentation.

Cost pressures are likely to continue as well. Across preliminary filings from 16 states and the District of Columbia, insurers are proposing a median 14% premium increase for 2027. Texas rates are not yet available, so that figure should not be treated as a state forecast. It does signal that rising medical and prescription-drug costs, a changing enrollee risk pool, and federal policy changes are shaping insurer decisions nationally.

Some market adjustments are already visible in Texas. Baylor Scott & White Health Plan has announced that it intends to discontinue its individual Marketplace plans after 2026. One insurer’s departure does not establish broad market instability, but it means affected consumers will need to select new coverage and confirm that their physicians and hospitals remain in network.

What Texas should watch

It is too early to conclude that the 2026 enrollment decline is undermining payer, primary care, or hospital sustainability. However, the combination of fewer active enrollees, weaker rural plan selections, shifting plan designs, and at least one insurer exit warrants close attention.

For consumers, the distinction between selecting and sustaining coverage is consequential. A person who cannot activate or retain a plan may delay routine care, interrupt medications, or lose access to clinicians already managing a health condition. Even those who remain insured may face greater financial exposure if they move to a lower-premium Bronze plan with a higher deductible. In this sense, the emerging risk is not only becoming uninsured but becoming insured on terms that make care harder to use.

The upcoming policy conversation should look beyond the headline open-enrollment total and track four questions:

Who successfully activates and retains coverage?

Are rural communities falling further behind?

Are Texans selecting plans they can afford to use, not just plans they can afford to enroll in?

And, are changes in enrollment beginning to affect household stability, provider networks, care continuity, or uncompensated care?

Texas’s Marketplace remains large and more resilient than the national market. But 2026 revealed an important distinction: plan selection remained high, while the pathway from choosing a plan to sustaining usable coverage became less reliable. The 2027 enrollment period will show whether that gap was a one-year adjustment or an early signal of a more consequential change in Texas’s coverage landscape.