Navigating the regulatory changes coming to health insurance in 2026 will be a significant challenge for actuaries and health insurance professionals. With a wave of policy shifts, rising premiums, and altered eligibility rules, staying compliant and managing risk effectively requires smart, adaptive strategies. If you’re an actuary or work in health insurance planning, understanding these changes and adjusting your approach is critical to helping your organization thrive in a more complex environment.
First, let’s talk about the key regulatory shifts that will shape the landscape in 2026. One of the biggest changes is the expiration of enhanced premium tax credits that have helped many ACA Marketplace enrollees afford coverage since 2021. Without these subsidies, premiums are expected to rise sharply — estimates suggest an average premium increase around 15-18%, with some areas experiencing even higher spikes[4][5]. This means fewer healthy individuals may find coverage affordable, potentially leading to a risk pool that’s sicker and more costly overall. Actuaries must anticipate these shifts in risk composition when projecting costs and setting rates.
Another major factor is new eligibility restrictions. Recent laws have removed premium tax credit eligibility for groups like DACA recipients and certain low-income lawfully present immigrants, affecting roughly 300,000 people who could lose coverage[2]. This regulatory tightening reduces the pool of subsidized enrollees, which again puts upward pressure on premiums and complicates risk management.
So, what practical actuarial strategies can help health insurers navigate these challenges and maintain compliance?
1. Refine Risk Pool Modeling
With the exit of healthier enrollees driven by subsidy expirations and eligibility changes, actuaries should update their predictive models to account for a sicker, more concentrated risk pool. This means incorporating assumptions about who is likely to drop coverage and adjusting morbidity and utilization estimates accordingly. It’s helpful to use scenario testing: what happens if 10%, 20%, or even 30% of lower-risk members leave? How does that impact claims costs and pricing? Running these models frequently as new data arrives can improve accuracy.
2. Leverage Data on Alternative Coverage Options
As premiums rise, some individuals may turn to alternatives like Short-Term Limited Duration Insurance or Health Care Sharing Ministries, which typically exclude higher-risk individuals[6]. Understanding the flow of enrollees between these alternatives and ACA plans can give insights into risk segmentation. Actuaries should monitor enrollment trends and adjust assumptions on risk selection and adverse selection effects. Awareness of these alternatives also helps in communicating coverage options to stakeholders.
3. Stay Abreast of Regulatory Updates
Regulatory environments can change quickly. For example, new rules about Medicaid eligibility and individual marketplace requirements might alter who qualifies for coverage or subsidies[2]. Actuaries should maintain close relationships with legal and compliance teams to get early warnings of changes. Participating in industry groups or attending regulatory briefings can provide foresight into upcoming policy shifts, allowing more proactive adjustments.
4. Communicate Clearly with Stakeholders
One of the trickiest parts of regulatory change is managing expectations. Actuaries should work closely with product teams, underwriters, and leadership to explain how regulatory shifts impact pricing, coverage options, and risk profiles. Using clear visuals and straightforward language to present complex actuarial concepts makes it easier for decision-makers to act confidently. For example, showing how the loss of subsidies could increase premiums by 15-20% helps prepare marketing and customer service teams to answer questions.
5. Consider Employer-Sponsored Solutions
The rise of Individual Coverage Health Reimbursement Arrangements (ICHRAs) means some employers are shifting employees to the individual market with employer-funded contributions[6]. This trend can affect the risk pool and enrollment patterns. Actuaries should factor in ICHRA adoption rates and the health status of these employees when modeling the individual market. Offering guidance on ICHRA design and funding levels can help employers maintain stable coverage for their workers while managing cost.
6. Embrace Technology and Automation
The complexity of 2026 compliance demands sophisticated tools. Automated rate filing systems, predictive analytics platforms, and compliance tracking software can streamline actuarial workflows and reduce errors. Investing in technology also enables faster scenario analysis and real-time data updates, which are crucial when regulations or market conditions shift unexpectedly.
A practical example: Imagine an insurer notices from early 2025 data that many healthier younger enrollees are not renewing their ACA plans, anticipating higher premiums in 2026. The actuarial team runs multiple scenarios assuming a 25% drop in low-risk members. They find this could increase claims costs by 10%, requiring a premium hike of around 15%. They present these findings to leadership, who then decide to offer targeted wellness incentives and tailored communications to retain healthier members as much as possible. Simultaneously, they prepare customer service teams to explain premium increases transparently.
The stakes are high because these regulatory changes will directly impact millions of Americans’ access to affordable health coverage. The Congressional Budget Office projects that changes to eligibility could leave hundreds of thousands uninsured[2], while rising premiums may price out more. For actuaries, this means balancing compliance with the need to design sustainable, affordable products that meet the evolving needs of enrollees.
Finally, it’s important to remember that change also brings opportunity. Navigating these regulatory shifts well can position insurers as trusted partners who help consumers find the best coverage amid complexity. Actuaries who stay ahead with data-driven insights and proactive strategies will be key drivers in shaping a more resilient health insurance market in 2026 and beyond.
By focusing on refined risk modeling, monitoring alternative coverage trends, maintaining regulatory vigilance, clear stakeholder communication, embracing employer-sponsored options, and leveraging technology, actuarial teams can confidently steer their organizations through this challenging period. With thoughtful preparation and adaptability, 2026 compliance doesn’t have to be a roadblock—it can be a catalyst for smarter, more responsive health insurance solutions.