Recent headlines have highlighted rising Affordable Care Act (ACA) plan enrollment in Texas, but statewide gains mask uneven trends across different communities, including urban communities and communities in rural Texas. While overall enrollment in Texas increased by about 5%, enrollment fell more than 3% in rural areas and dropped roughly 5% in exurban counties, or metropolitan counties where at least one-third of residents live in rural-designated census blocks.

Across the country, ACA Marketplace plan selections fell by more than one million people to 23.1 million in 2026, the largest year-over-year decline since the marketplaces were created over a decade ago.

Actual enrollment is expected to drop even further because many consumers may not pay their premiums or may cancel coverage during the year as higher costs, following the expiration of enhanced premium tax credits, make plans less affordable.

With enhanced premium tax credits expiring, average monthly costs for ACA Marketplace enrollees rose 58% in 2026, leading many consumers to choose cheaper plans with higher out-of-pocket costs and pushing deductibles up by more than $1,000 on average—the largest jump in the marketplace history.

“Rural enrollees may be shifting to lower tier plans that require more out-of-pocket costs or dropping healthcare coverage altogether because of recent Marketplace changes,” said Alexa McKinley Abel, director of government affairs and policy at the National Rural Health Association (NRHA). “Increases in ACA premiums combined with recently finalized regulations that incentivize enrollment in bronze and catastrophic plans will lead to higher healthcare costs for rural populations, and ultimately less access to care. These costs may come in the form of paying the higher premiums themselves, less generous coverage leading to higher out-of-pocket costs, or expensive medical bills for those who are no longer insured.”

Texas remains an outlier nationally, posting enrollment growth even as Marketplace sign-ups fell across the country. Still, signs of the national affordability squeeze are emerging in rural parts of the state, where rising premiums are coinciding with sharp enrollment declines. Texas has the country’s largest rural population and the disproportionate impact in these communities is already visible in Central Texas.

Read the full article about rural communities' Affordable Care Act coverage by Madeline de Figueiredo at The Daily Yonder.