Recent headlines have highlighted rising Affordable Care Act (ACA) plan enrollment in Texas, but statewide gains mask uneven trends across different communities. 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.
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Bastrop and Caldwell counties sit just southeast of Austin and are part of the region’s fast-growing exurban corridor, where rural communities are increasingly tied to the Austin and San Antonio metro areas through commuting patterns and population growth. Despite their proximity to major urban health care hubs, both counties still face limited local provider capacity compared with core urban areas, along with higher poverty rates and more constrained local resources that can make it harder for residents to absorb rising health care costs.
In Bastrop County, ACA enrollment dropped over 17% as average monthly premiums increased $100. In Caldwell County, ACA enrollment dropped 10% as average monthly premiums increased over $50.
Those declines are particularly significant for areas that already have high uninsured rates. Census data from 2024 indicated that about 21.2% of Bastrop County residents and 22.5% of Caldwell County residents lacked health insurance, raising concerns that falling Marketplace enrollment could further widen gaps in access to care in communities that already rely heavily on limited local providers and safety-net services.
This trend was not unique to Texas. In Louisiana, statewide enrollment grew about 1%, but enrollment fell more 1.7% in rural counties and over 2% in exurban counties. “About 29% of Louisiana’s residents live in rural areas and many of those individuals are self-employed or employed by small businesses that do not offer employer-sponsored coverage. Those who don’t qualify for Medicaid often relied on the premium tax credit to afford health coverage. We are concerned that elimination of this tax credit will lead to an increase in uninsured patients in our rural communities,” said Denaé M. Hebert, executive director of the Louisiana Rural Health Association. “A lack of health coverage is not only harmful to those patients, but also puts additional financial stress on rural providers that care for them. With many of our rural hospitals already operating on tight margins, increases in uncompensated care would be detrimental to the financial stability of these vital community hospitals.”
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This pattern was reflected in the distribution of enrollment changes across both states. Roughly one-third of rural counties (33%) and exurban counties (32%) saw ACA enrollment fall by at least 7.5%, compared with just 14% of metro counties. Meanwhile, metro counties were nearly twice as likely as rural counties to post enrollment gains of at least 7.5%.
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Even in states that defy national enrollment declines, rural and exurban areas are still experiencing losses driven by rising costs and reduced affordability.
Coverage losses could quickly become care barriers in rural communities.
“Under-and and uninsurance are strong factors for rural individuals choosing to delay or forgo care, leading to worsening health outcomes,” Abel said.
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