A record 23.1 million Americans signed up for Affordable Care Act marketplace coverage during the most recent open enrollment period, according to the Centers for Medicare and Medicaid Services. Many of them are now opening premium bills that look nothing like last year’s.
Across dozens of insurer filings submitted to state and federal regulators for the 2026 plan year, gross premium rates, the sticker price before federal subsidies, climbed by roughly 26% or more in numerous markets. No single federal source publishes that figure as a tidy national average, but the pattern is consistent enough across filings in the CMS rate review database to signal a sharp, broad-based increase. For the millions of enrollees who earn too much to qualify for premium tax credits, every dollar of that increase hits their bank account directly.
The usual cost drivers are all present: hospital price inflation, a post-pandemic surge in people actually using their coverage, and shifts in who is buying plans. But one factor keeps appearing in rate filings that barely registered three years ago: GLP-1 medications like Ozempic, Wegovy, and Mounjaro. Prescribed for Type 2 diabetes and, increasingly, for obesity, these drugs carry list prices that can exceed $1,000 a month per patient. When adoption accelerates across a risk pool of tens of millions, the pharmacy spending line swells fast.
What the federal numbers reveal
The CMS 2026 pricing fact sheet breaks out projected average premiums on HealthCare.gov both before and after advance premium tax credits. That distinction matters enormously. Subsidized consumers who pick the lowest-cost plans may see only modest changes because tax credits absorb much of the increase. Unsubsidized buyers face the gross premium head-on.
To put the increase in concrete terms: a 40-year-old buying a mid-tier Silver plan in a moderately priced market might have paid around $500 a month in gross premiums for 2025. A 26% increase pushes that to roughly $630, an additional $1,560 a year, with no federal cushion if that person earns above the subsidy cliff.
The record enrollment figure amplifies the financial stakes. Every percentage point of premium growth translates into billions of additional dollars cycling through the marketplace. And because the ACA risk pool now includes a far broader cross-section of the population than in its early years, expensive new therapies affect a much larger base of covered lives than they once would have.
Within the CMS rate review database, the single risk pool filing worksheets lay out the assumptions insurers used when projecting medical cost trends, pharmacy spending growth, and utilization shifts. While the public-use files do not isolate spending on Ozempic or other GLP-1 drugs by name, pharmacy trend assumptions in many filings reflect double-digit growth rates consistent with the rapid adoption of these medications.
At least one state regulator is not buying it
Not every regulator is accepting insurers’ math at face value. In September 2025, the Massachusetts Division of Insurance formally rejected a 2026 rate filing from Blue Cross Blue Shield of Massachusetts, one of the state’s largest carriers. The disapproval forced the insurer to refile with revised assumptions, a move that could ultimately lower what Massachusetts consumers pay.
The rejection stands out because it shows a regulator concluding that a major insurer’s projected cost trends did not hold up under scrutiny. The full actuarial record behind the decision has not been publicly summarized in enough detail to confirm whether GLP-1 spending was a specific point of contention. But the action itself sends a signal: at least one state is treating large rate requests as something to challenge, not rubber-stamp. Other states with active rate review authority, including New York, Connecticut, and Oregon, have the tools to do the same, though their 2026 decisions have drawn less public attention.
How much of the increase is actually about Ozempic?
The connection between GLP-1 drugs and rising premiums is real, but isolating a precise national number remains difficult. No publicly available federal dataset separates the share of ACA premium increases driven by semaglutide or tirzepatide prescriptions from other cost pressures like hospital consolidation, specialty drug spending outside the GLP-1 class, or changes in enrollee risk mix.
What exists is directional evidence from multiple angles. In rate filings and regulatory proceedings, some carriers have projected that GLP-1 drugs add several percentage points to their overall medical cost trend. Others report a smaller effect because prior authorization requirements and step-therapy protocols limit how many patients actually fill prescriptions. These estimates appear in individual insurer filings available through the CMS rate review database and in state-level rate hearing documents, but no independent actuarial organization has published a consensus national figure. The range of estimates is wide enough that no single number should be treated as definitive.
There is also a timing question. Many ACA marketplace enrollees have lower incomes and may face stricter coverage criteria for weight-loss indications than workers in large employer plans. If manufacturers lower net prices, as Novo Nordisk has begun to do with authorized generic versions of some products, or if biosimilar competition arrives on schedule, the pharmacy cost curve could flatten. If clinical evidence broadens approved uses or coverage restrictions loosen, costs could climb further. Current rate filings are essentially bets on which scenario plays out, and those bets vary from carrier to carrier.
The subsidy cliff and the congressional wild card
Any discussion of ACA affordability in 2026 is incomplete without mentioning the enhanced premium tax credits that Congress first authorized under the American Rescue Plan in 2021 and extended through the Inflation Reduction Act. Those enhanced subsidies, which cap marketplace premiums at 8.5% of household income for eligible buyers and eliminate the old income ceiling for subsidy eligibility, were set to expire at the end of 2025. Congressional action to extend them has been a moving target, and the outcome directly shapes how much of the gross premium increase consumers actually feel.
If the enhanced credits remain in place, most subsidized enrollees are at least partially shielded. If they lapse or are scaled back, millions of middle-income buyers could face the full force of a 26% gross increase on top of losing the extra subsidy protection they have relied on for the past several years. That combination would represent the sharpest affordability squeeze the ACA marketplace has seen since its early years.
What consumers can actually do right now
For people shopping on HealthCare.gov or a state-based exchange, the gross premium headline can be misleading. After tax credits, the lowest-cost Silver and Bronze plans remain affordable for many subsidy-eligible enrollees, according to the CMS fact sheet. The pain concentrates among those who earn above the subsidy threshold: self-employed workers, early retirees, and small-business owners who buy individual coverage. For them, a roughly 26% gross increase is not an abstraction. It is a larger monthly bill with no federal cushion.
A few steps are worth taking before the next enrollment window:
- Run an updated subsidy estimate. Income changes, household size shifts, and benchmark plan adjustments can all alter your tax credit. The calculator on HealthCare.gov reflects current-year figures.
- Compare plans aggressively. Premiums vary dramatically by geography and by metal tier. Switching from a Gold to a Silver plan, or from one insurer to another in the same county, can sometimes offset rate increases entirely.
- Check formulary details. If you take a GLP-1 or any other high-cost medication, confirm that your plan’s formulary and prior authorization rules have not changed. Coverage terms shift year to year, and a plan that covered your prescription in 2025 may impose new restrictions in 2026.
Breakthrough drugs and affordable coverage are on a collision course
GLP-1 drugs present a policy puzzle that outlasts any single enrollment cycle. If Ozempic, Wegovy, and similar medications deliver on their clinical promise, they could eventually reduce spending on heart disease, kidney failure, and other costly complications of obesity and diabetes. Some early cardiovascular outcome studies suggest exactly that. But “eventually” does not help an insurer setting rates for the next 12 months, and it does not help a consumer staring at a premium notice in May 2026.
The evidence as of spring 2026 supports a qualified but clear conclusion: ACA premiums are climbing steeply, GLP-1 drugs are a meaningful part of the reason, and the exact size of their contribution varies by insurer, state, and how aggressively regulators scrutinize the math. As more claims data accumulates and regulators push for more granular cost disclosures, the picture should sharpen. Until then, millions of Americans are navigating a market where breakthrough medicine and insurance affordability are pulling in opposite directions, and no one in Washington or the insurance industry has offered a clean answer for how to reconcile the two.
