Nearly 900,000 Texans Selected a Health Plan but Never Activated It

More than 4.17 million Texans selected an Affordable Care Act Marketplace health insurance plan for 2026. That sounds like an enormous enrollment success. But selecting a plan is not the same as having active health insurance.

By February 1, roughly 895,000 of those Texans had not activated — or “effectuated” — their selected plans. In most cases, Marketplace coverage does not become active until the enrollee pays the first monthly premium. That left approximately 3.28 million Texans with active Marketplace coverage at that point.

Some people may have completed their payments after February 1 because of applicable payment deadlines or grace periods. Still, the size of the initial gap raises an important question: why would hundreds of thousands of people take the time to apply, compare plans, and select coverage, but fail to activate it?

The answer may reveal one of the biggest problems in the American health insurance system. People want coverage. Many simply cannot afford what it costs to keep it.

Selecting a plan does not mean someone is insured

Marketplace enrollment numbers can create the impression that everyone who selected a plan successfully obtained coverage. The reality is more complicated.

A consumer can complete an application, qualify for financial assistance, and select a plan — but the insurance company generally will not activate the policy until the first premium is paid. CMS specifically distinguishes between a plan selection and an effectuated enrollment. That distinction matters.

A family may find a plan that appears manageable while completing its application. When the first bill arrives, however, that family may have to choose between health insurance and other immediate expenses such as rent, groceries, transportation, childcare, and utilities.

Others may have been automatically reenrolled from a previous year without realizing that their new plan required a payment. Someone who previously had a zero-dollar premium could suddenly owe money each month and lose coverage by failing to make the new payment.

Why Marketplace coverage got more expensive in 2026

The enhanced premium tax credits created under the American Rescue Plan expired at the end of 2025. These enhanced credits had reduced monthly premiums for millions of Marketplace consumers and extended assistance to some middle-income households that previously earned too much to qualify.

After the enhanced credits expired, many consumers received less financial assistance in 2026. People earning more than 400% of the federal poverty level were hit particularly hard, because the previous 8.5% income cap on benchmark plan premiums no longer applied to them.

According to KFF, the average monthly Marketplace premium paid after tax credits rose from $113 in 2025 to $178 in 2026 — a 58% increase. For a household already squeezed by inflation, an extra $65 a month is not insignificant. It adds up to $780 a year, and some households saw considerably larger increases. In a KFF survey conducted after the enhanced credits expired, half of returning enrollees said their healthcare costs were “a lot higher” in 2026.

Faced with higher premiums, some people left the Marketplace. Others cut their monthly cost by choosing plans with greater financial exposure when they actually need care. Here is how the averages moved:

This creates a difficult choice. A person can pay a higher premium for stronger benefits, pick a cheaper plan with a larger deductible, or remain uninsured and hope nothing serious happens. None of those options feels particularly affordable.

This is not only a Texas problem

Texas is a dramatic example because it has one of the country's largest Marketplace populations. But the underlying affordability problem exists nationwide. Roughly 27 million Americans remain uninsured, and the United States is one of only two countries in a 20-country Commonwealth Fund analysis where a substantial share of the population lacks coverage.

Being insured does not necessarily solve the problem. Nearly one in four American adults who kept coverage all year were considered underinsured — their deductibles and out-of-pocket costs were so high relative to income that they still struggled to get care. Many insured Americans postpone doctor visits, delay procedures, skip diagnostic testing, or don't fill prescriptions because they can't afford their share of the bill.

That is the contradiction at the center of American healthcare. The country spends more on healthcare than any comparable nation — about 18% of GDP in 2024, nearly twice the OECD average — yet Americans still face some of the highest out-of-pocket costs for care and prescriptions. We pay more, but millions remain uninsured or afraid to use the coverage they have.

America has an affordability problem

The public conversation about health insurance usually focuses on enrollment: how many people signed up, how many plans were selected, how many qualified for a subsidy. Those numbers matter, but they don't tell the whole story.

The more meaningful questions are whether people can pay their first premium, keep up the monthly payments, and afford to use the coverage after it becomes active. A policy with an affordable premium but an unaffordable deductible may not offer a family meaningful protection. A comprehensive plan that eats too much of a household's monthly income may not stay active for long. Coverage only succeeds when people can afford both the insurance and the healthcare.

The nearly 900,000 Texans who selected plans but hadn't activated them by February 1 should not be dismissed as people who didn't care about being insured. They applied. They evaluated their choices. They selected a plan. The process broke down between wanting coverage and being able to pay for it. That is an affordability problem.

The cost of going without coverage

When people can't afford health insurance, they don't stop needing healthcare. They delay it. A minor issue can become a major condition. A manageable chronic illness can become an emergency. Preventive care gets replaced by emergency room treatment, which is usually more expensive for both the patient and the system.

Uninsured families can also face medical bills that disrupt their finances for years. And even insured families are exposed when deductibles, coinsurance, and prescription costs outrun their savings. Health insurance is supposed to protect people from catastrophic financial loss. When the premium or the cost of using the plan is out of reach, that protection starts to disappear.

What Texans should take from this

Health insurance decisions should not be based on the monthly premium alone. Before you accept a renewal or, worse, drop coverage entirely, work through this:

1. Look past the premium. Understand the deductible, copays, coinsurance, prescription coverage, provider network, and maximum out-of-pocket exposure. A plan that looks cheap at enrollment can become costly when you actually need care.
2. Don't rely on an automatic renewal. If you were reenrolled without reviewing the new premium, you may owe money you weren't expecting — and miss the first payment. Re-shop every plan in your county.
3. Recheck your subsidy with an accurate income estimate. Many Texans still qualify for a meaningful credit even after the enhancement expired. Report changes in household income or family size when required.
4. Compare the metal tiers. If you're eligible for cost-sharing reductions, a Silver plan can be far richer than it looks. If you're healthy and just over the subsidy cliff, it can be worth pricing an off-marketplace plan.
5. Talk to a licensed advisor before deciding. Getting the income estimate and the tier right is where the savings live — and where a missed first payment can be avoided.

The goal is not simply to enroll in something. The goal is to find coverage you can realistically keep and actually use.