Editor’s Note: This post is from our data newsletter, the Rural Index, headed by Sarah Melotte, the Daily Yonder’s data reporter. Subscribe to get a weekly map or graph straight to your inbox.
Rural residents in states that participate in the Affordable Care Act (ACA) Marketplace are losing health insurance coverage at higher rates than their urban and suburban counterparts, according to my analysis of data from the Centers for Medicare and Medicaid Services (CMS).
Covid-era healthcare subsidies, which were established under the American Rescue Plan Act of 2021 and extended through the Inflation Reduction Act of 2022, temporarily extended who was eligible for lower health insurance premiums. Under these extensions, people with incomes at or above 400% of the Federal Poverty Level (equal to about $132,000 for a family of four) were eligible to receive healthcare subsidies through Enhanced Premium Tax Credits.
Enhanced subsidies were scheduled to end at the end of 2025, and GOP lawmakers refused to renew them in President Trump’s July 2025 budget reconciliation bill, which initiated the largest wealth transfer from working-class residents to the wealthy in America’s history, affording millionaires larger tax cuts than the bottom half of Americans combined. People who are no longer eligible for these subsidies have accounted for a disproportionate share of health insurance coverage drops, resulting in increases in monthly premiums for nearly all consumers.
Nationwide, enrollment in the ACA Marketplace dropped while premiums increased, but this change is happening the most drastically in nonmetropolitan, or rural, counties.
In nonmetropolitan counties, the number of people signed up during the open enrollment period dropped by approximately 12%, representing 29,000 consumers. Small metropolitan counties saw a drop of 11%, representing about 154,000 consumers, the next largest decrease in enrollment among all of the county types. The drop out rate among the 30 states that used the ACA Marketplace platform in 2026 was 8%, representing nearly 1.4 million consumers.
(Note: Major metro core areas are cities in counties that have more than one million residents. Medium-sized cities are in counties that have populations between 250,000 and one million residents. And small metros have populations fewer than 250,000 residents. Nonmetropolitan areas are counties outside of the Office of Management and Budget’s list of Metropolitan Statistical Areas.)
The data for this analysis came from the CMS County-level Open Enrollment file, which includes healthcare plan selections and monthly premiums by county, updated on an annual basis. The file also includes demographic information, like the age, gender, race, and income of exchange plan consumers.
The following map shows the change in average monthly health insurance premiums among nonmetropolitan counties from 2025 to 2026. (Remember that my analysis only includes data from the 30 states that used the ACA Marketplace platform in 2026.)
Data from the open enrollment period will show higher sign-up rates than effectuated enrollment, or the number of people who will actually be able to afford their monthly premiums throughout the year. A KFF Health News survey from earlier this year showed that 9% of ACA Marketplace enrollees had become uninsured since the open enrollment period, while 17% of returning consumers indicated that they were not sure if they could afford their premiums for the rest of the year.
Under the Enhanced Premium Tax Credits, consumers with incomes above 400% of the Federal Poverty Level had their premiums for a benchmark silver plan capped at 8.5% of their income. This demographic accounted for a disproportionate share of the drop in sign-ups, according to a KFF Health News analysis of nationwide data. While those above the so-called “subsidy cliff” comprised about 3% of total enrollees, they accounted for 27% of the drop in sign-ups between 2025 and 2026. The KFF analysis included all 50 states, including the states that didn’t participate in the ACA Marketplace in 2026 and opted for state-based exchanges.
People with lower incomes – who still receive federal financial assistance – saw their premiums increase, but not as drastically, and drop-outs were not as high among this group.
The following graph shows which counties were hit the hardest by premium increases after tax credits, depicting the share of counties in each premium-increase quartile.
Most of the counties with the highest increase in premiums even after tax credits were nonmetro communities, which accounted for 532 of the 778 counties in the top quartile. Twenty-seven percent of nonmetro counties were in this quartile.
Some of the places that saw a stable number of sign-ups benefited from state-level policies that offset the loss of federal assistance. In 2025, the Colorado State Legislature introduced Colorado Premium Assistance, a fund meant to reduce premiums for certain eligible consumers, for example. In New Mexico, ACA Marketplace enrollment rates increased by 18%, reflecting the state’s health insurance affordability plan.
