The Real Cost of ACA Coverage by State in 2026
For the broader ACA context, start with ACA Health Insurance for Early Retirees: The Complete Guide. This piece focuses specifically on state-level variation — what’s driving it, what it looks like in dollar terms, and how to think about geographic arbitrage in your coverage planning.
Why state variation is so large
The Affordable Care Act is federal law, but its implementation is state-by-state in several important ways:
Insurer competition varies. Some states have 8–12 insurers competing on the marketplace. Others have 1–2. More competition generally means lower premiums. Rural counties in any state tend to have fewer insurers than metropolitan areas.
Rating areas are state-determined. Each state defines geographic rating areas for its marketplace. Premiums within a rating area are uniform for a given age and plan, but adjacent rating areas in the same state can have materially different prices.
Medicaid expansion status affects the whole market. States that expanded Medicaid under the ACA moved millions of lower-income adults out of the marketplace risk pool, leaving healthier enrollees in the marketplace pool and pushing premiums down. Non-expansion states have sicker, more expensive marketplace risk pools, pushing premiums up.
State-based exchanges compete with federal. About 20 states plus DC operate their own marketplaces; the rest use healthcare.gov. State-based exchanges can customize enrollment periods, offer additional subsidies, and sometimes negotiate more aggressively with insurers.
Reinsurance programs vary. Some states run reinsurance programs (often using 1332 waivers) that subsidize insurer losses on high-cost enrollees, effectively reducing premiums across the market. States with robust reinsurance typically have 10–30% lower premiums than they would otherwise.
State-funded supplemental subsidies. A handful of states provide additional premium assistance beyond the federal premium tax credit. Where available, these programs can dramatically reduce the effective cost for enrollees, especially since the enhanced federal PTCs expired.
The three premium tiers
Roughly speaking, 2026 premiums cluster into three tiers based on these factors. Exact prices in your county vary; use healthcare.gov’s plan finder for specifics.
High-premium states
States where full-price benchmark Silver plans run highest, often where insurer competition is limited, rural geography dominates, or reinsurance is minimal:
Wyoming. Historically one of the highest-premium states in the country. A 60-year-old couple can see benchmark premiums of $2,500–$3,200 per month.
Alaska. High medical costs, limited insurers, geographic challenges. Comparable to Wyoming on benchmark premiums.
West Virginia. Limited competition, older risk pool, non-expansion effects in recent history (West Virginia has expanded Medicaid but carries legacy market dynamics).
Vermont. State-based exchange but small population, high underlying medical costs, limited insurer competition.
Rural counties in Texas, Georgia, North Carolina. Individual rural counties in non-expansion states or states with concentrated urban competition can match Wyoming or Alaska pricing even when the state as a whole is cheaper.
In these markets, a 60-year-old couple earning just over 400% FPL ($86,560) faces roughly $28,000–$35,000 in unsubsidized annual premiums — the full cost once the cliff eliminates subsidies.
Moderate-premium states
The bulk of the country. Premiums are significant but not extreme:
Texas. Largest non-expansion state, which keeps premiums elevated, but competitive urban markets (Houston, Dallas, Austin) offer multiple insurers.
Florida. Non-expansion state with the largest marketplace enrollment in the country. Premiums moderate given the volume, but the cliff still creates meaningful exposure.
Georgia, Tennessee, Mississippi, Alabama. Non-expansion states with variable insurer participation. Rural areas often worse than urban.
Arizona, Nevada, North Carolina, Indiana, Ohio. Moderate insurer competition, some state-level market stability measures.
Pennsylvania, Michigan, Wisconsin. Large state-based or hybrid markets with reasonable insurer competition.
For a 60-year-old couple in moderate-premium markets, benchmark annual premiums typically run $20,000–$25,000 before subsidies. Crossing the 400% FPL cliff costs $12,000–$17,000 per year in lost premium assistance.
Lower-premium states
States with robust insurer competition, effective reinsurance, state-based exchanges, Medicaid expansion, and sometimes state supplemental subsidies:
Massachusetts. Original source of the individual-mandate-plus-subsidy-plus-marketplace model. Strong insurer competition, state-based exchange, robust reinsurance. Typically the lowest marketplace premiums for older adults in the country.
Minnesota. State-based exchange (MNsure), strong reinsurance program, competitive insurer market.
New Mexico. State-based exchange, Medicaid expansion, growing insurer participation.
New York. State-based exchange, strong insurer competition in metropolitan areas, state supplemental programs.
Washington, Oregon, California. State-based exchanges, Medicaid expansion, some form of supplemental state assistance.
Maryland, New Jersey, Connecticut, Rhode Island, DC. State-based exchanges with state-level supplemental programs.
For a 60-year-old couple in lower-premium markets, benchmark annual premiums run $14,000–$18,000 before subsidies. Cliff cost $6,000–$10,000 per year.
Medicaid expansion and the coverage gap
As of 2026, approximately 41 states plus the District of Columbia have adopted full Medicaid expansion under the ACA. About 10 states have not fully expanded, though several have implemented partial expansions or work-requirement programs that cover some of the gap population.
For early retirees, Medicaid expansion status matters in two ways:
If your income is very low, Medicaid expansion states cover adults with incomes up to 138% FPL regardless of other categorical eligibility. For an early retiree living primarily on already-taxed assets with minimal reportable income, Medicaid may be available. Non-expansion states generally don’t cover childless adults through Medicaid, creating a “coverage gap” for people with income too low for marketplace subsidies (which require at least 100% FPL) but too high for traditional Medicaid eligibility.
If your income is marketplace-eligible, expansion vs. non-expansion status affects broader premium levels as described above. You’re less likely to see extreme premium spikes in expansion states because the overall risk pool is healthier.
Non-expansion states as of 2026 (approximate list — verify current status with KFF or your state): Texas, Florida, Tennessee, Mississippi, Alabama, South Carolina, Wyoming, Kansas, and others. Georgia operates a partial expansion via work requirements (the Pathways program). North Carolina expanded in 2023; Missouri in 2021; South Dakota in 2023.
If you’re planning early retirement and your retirement income will be low, expansion status is a meaningful geographic consideration. The coverage gap in non-expansion states can leave low-income retirees without affordable coverage options.
State-funded supplemental subsidies
A handful of states provide premium assistance beyond the federal premium tax credit. With enhanced federal PTCs expired in 2026, these state programs have become more significant for absorbing some of the cost increases.
California (Covered California). State supplemental subsidies for enrollees at various income levels, including some assistance for middle-income enrollees above 400% FPL. California’s program partially offset the federal cliff for California enrollees in 2026.
New Jersey (Get Covered New Jersey). State subsidy program for lower-income enrollees, plus outreach and affordability initiatives.
Washington (Cascade Care Savings). State subsidies for households up to 250% FPL, and a standardized plan design that improves comparability.
Colorado. Health Insurance Affordability Enterprise provides state-funded subsidies for specific income bands.
Maryland. Young adult subsidy program and state reinsurance.
Connecticut, Rhode Island, Vermont, New York, DC. Various state-specific subsidy and reinsurance programs.
State subsidy details change frequently. Check your state marketplace directly for current programs. Note that state supplemental subsidies are typically smaller than the federal enhanced PTCs that expired — they don’t fully offset the federal cliff, but they reduce the impact in the states that offer them.
How to look up your state
The most reliable path for current 2026 pricing in your specific area:
- Go to healthcare.gov (if your state uses the federal exchange) or your state’s exchange directly.
- Start a plan application with your actual household size and projected income.
- Browse available plans with their real post-subsidy prices for your county, age, and tobacco status.
- Compare benchmark Silver, other Silver options, Bronze, and Gold to understand the trade-off.
Don’t rely on third-party premium aggregators for current pricing. They’re often outdated, and insurer participation, plan details, and subsidy math all changed in 2026 with the enhanced PTC expiration and OBBBA implementation.
Special cases worth knowing
Non-expansion states with the coverage gap. If your projected income is below 100% FPL and you live in a non-expansion state, you may fall into the gap — above Medicaid eligibility (which for adults without children in non-expansion states can be effectively zero) but below marketplace subsidy eligibility. Options in the gap are limited: find employer coverage, work enough to get above 100% FPL, or move to an expansion state. Geographic arbitrage for retirement planning can be meaningful in this specific circumstance.
State tax implications. Some states have income tax; some don’t. Your state of residence affects your total tax picture separately from your ACA math. For retirees doing Roth conversions, a no-state-tax state (Florida, Texas, Tennessee, Washington, Nevada, Wyoming, South Dakota, Alaska) saves on state conversion tax but may have higher marketplace premiums (Texas, Wyoming, Alaska are higher-premium markets). The combined picture matters more than any single factor.
HDHP availability. To contribute to an HSA, you need coverage from a qualifying High-Deductible Health Plan. Not all marketplace Silver plans qualify as HDHPs, even though they may meet the deductible threshold — HSA-compatibility requires specific plan design. Check plan details carefully, and look for plans explicitly labeled “HSA eligible” on the marketplace.
Geographic mobility during retirement. Coverage is state-specific. Moving states during the year typically triggers a special enrollment period, letting you enroll in your new state’s marketplace. Premium, subsidy, and plan structure will reset based on the new location. For people considering retirement relocation, the cost of coverage should factor into the decision alongside taxes and cost of living.
Try Nexus
Model state-specific ACA coverage costs
Enter your projected MAGI and location — Nexus pulls representative benchmark pricing for your area, factors in any available state supplemental subsidies, and projects your annual premium obligation year by year through Medicare eligibility. Pro tier includes state-comparison scenarios for relocation planning.
Open Nexus →Frequently asked questions
How often do ACA premiums change?
Every year. Insurers file new rate proposals each summer for the following coverage year, and state regulators review them. By open enrollment in the fall, the approved rates are public. Year-over-year changes of 10–25% in either direction aren't unusual, especially following major policy changes like the 2026 enhanced PTC expiration.
Can I shop across state lines for cheaper coverage?
No. ACA coverage is state-specific. Your plan is determined by your residence, and you can only enroll in plans available in your state and county. Moving states triggers new coverage options; traveling temporarily doesn't.
Do state-based exchanges have different open enrollment dates than healthcare.gov?
Sometimes. The federal healthcare.gov open enrollment typically runs November 1 to January 15. Some state-based exchanges extend their open enrollment windows — California and New York have historically run longer. Check your state's marketplace for current dates.
Are plans from state-based exchanges better than those on healthcare.gov?
Not inherently. The federal ACA rules apply either way. State-based exchanges can offer additional features like supplemental subsidies, extended enrollment, or curated plan comparison tools, but the underlying plan quality depends on the insurers participating, not on the exchange platform itself.
What if I move to a different state mid-year?
A permanent move triggers a special enrollment period in your new state's marketplace. You have 60 days from the move to enroll in new coverage. Your previous state's coverage ends when your new coverage begins; you're not double-covered. Subsidy calculations restart based on your new location's plans and premiums.
Do states with Medicaid expansion have lower marketplace premiums?
On average, yes — expansion states have healthier marketplace risk pools because the lowest-income (often sickest) enrollees are in Medicaid instead of the marketplace. The exact effect varies by state, but expansion states typically have 10–20% lower marketplace premiums than comparable non-expansion states.
Can state supplemental subsidies combine with federal premium tax credits?
Yes, in most cases. State subsidies are additive to federal PTCs. You apply once through the marketplace, which calculates both federal and state assistance, and your net premium reflects the combined subsidy. Program specifics vary by state.
Why is Wyoming so much more expensive than neighboring states?
Several factors: small population spread across large geography, limited insurer competition (often only one or two insurers participating), higher per-service medical costs due to rural provider dynamics, and no state reinsurance program. Wyoming has historically been among the 2–3 most expensive marketplace states in the country.
Do premiums scale the same way in every state?
The age-based premium scaling is federally capped (3:1 ratio between oldest and youngest rates for the same plan), so the shape of the age curve is similar across states. The absolute levels at each age differ dramatically based on the market. A 60-year-old pays roughly 3x what a 24-year-old pays in the same state for the same plan.
How do I factor premium differences into a retirement relocation decision?
Calculate the annual difference in premiums between your current state and your target state, multiplied by the years until Medicare eligibility. A $15,000 annual premium difference over 10 years of pre-Medicare coverage is $150,000 — meaningful relative to state tax differences, cost of living, and other relocation considerations. Nexus Pro runs state-comparison scenarios that make this math explicit.
Sources
Chris Gammill is the founder of Ignis Tools and writes about tax-aware retirement planning. Research and drafting assisted by AI tools; all figures and claims verified by the author against primary sources. State program details change frequently — verify current status with your state marketplace before making planning decisions.
- Healthcare.gov — Federal Marketplace Plan Finder — retrieved 2026-04-20
- KFF — State Health Insurance Marketplace Types — retrieved 2026-04-20
- KFF — Status of State Medicaid Expansion Decisions — retrieved 2026-04-20
- KFF — ACA Marketplace Premium Payments Would More than Double on Average Next Year — retrieved 2026-04-20