Kaufman Hall's July 2026 metrics show a calendar year-to-date operating margin index of 1.4% and a single-month index of 1.1%, with bad debt and charity care per day up 14% year over year. The more useful number for 2027 budgeting is not the enrollment decline but the deductible: the average ACA Marketplace deductible rose 37% to a record $3,786, almost entirely because enrollees bought down to bronze. That is a patient-responsibility exposure increase on patients who still have cards.
Kaufman Hall's July 2026 metrics, released in mid-September, put the calendar year-to-date operating margin index at 1.4% and the single-month operating margin index at 1.1% — both figures including health system allocations for shared services costs. That distinction is not pedantic. The same index without allocations can run materially higher, so any budget conversation citing "the Kaufman Hall margin" should specify the period and allocation treatment.
The July deterioration was sharp: calendar year-to-date operating margin fell from 2.2% in June to 1.4% in July — a decline of 0.8 percentage points. Kaufman Hall also reported that July year-to-date operating margin was 8% below the comparable 2025 level. Kaufman Hall linked the month to soft outpatient and elective-surgery activity; daily operating room minutes fell 3% month over month, net patient service revenue per adjusted discharge fell 3%, and discharges rose 2%.
July's margin decline appears primarily associated with volume, mix, and seasonal outpatient/OR dynamics. The monthly report alone does not establish ACA coverage loss as the cause. Kaufman Hall reports bad debt and charity care per day up just 1% month over month but 14% year over year in July, while bad debt and charity care as a share of gross operating revenue was up 5% year over year. Fourteen percent year-over-year growth on a line item that was already elevated is the number that belongs in a 2027 budget memo. The July margin print is the number that belongs in a Q3 variance explanation. They are different conversations.
Almost every 2027 budget assumption I have seen discussed since spring is built around an enrollment count: how many people fell off Marketplace coverage after the enhanced premium tax credits expired at the end of 2025, and what share of those became self-pay. That is a real question. KFF's analysis puts 2026 plan selections at 23.1 million, down by more than a million — the sharpest single-year drop since the Marketplaces launched. KFF projected in May that average monthly effectuated Marketplace enrollment could fall to about 17.5 million in 2026, from 22.3 million in 2025, applying a Wakely Consulting Group range of a 17% to 26% individual-market decline. Early CMS data later showed February 2026 effectuated enrollment of approximately 19.2 million, down from 21.8 million a year earlier. KFF's own follow-up survey found 9% of 2025 Marketplace enrollees had become uninsured.
The variable that is already measurable — and that is arguably larger in dollar terms — is the deductible.
KFF's analysis of the 2026 Open Enrollment public use files shows the average ACA Marketplace deductible rose 37% — $1,027 per person — from $2,759 to $3,786, a record and the steepest single-year increase since 2014. The metal mix moved hard. Bronze went from 30% of selections (7.3 million) to 40% (9.2 million). Silver fell from 57% (13.7 million) to 43% (9.8 million) — the first year under half. Gold rose from 13% to 17%.
The most consequential piece for a revenue cycle is the cost-sharing reduction collapse. In 2025, 66% of CSR-eligible consumers on the federal platform selected a silver CSR plan. In 2026, 45% did. The share of all Marketplace consumers holding a CSR plan fell to 37%, a record low. KFF's illustration: the average silver deductible available to someone at 150% of poverty is $80, against $5,304 for a standard silver plan. People traded a near-zero deductible for a near-zero premium and took a four-figure deductible with them.
For a hospital, this is not a coverage-loss event. These patients present with active insurance, clean eligibility checks, and a card that scans. They may carry substantially greater patient-responsibility exposure before plan payment begins.
Open enrollment for 2027 coverage runs November 1, 2026 through January 15, 2027, with December 15 the deadline for January 1 effective dates. Three things are modelable without waiting for enrollment data.
First, add deductible and patient-responsibility exposure as a separate reserve driver alongside uninsured volume, Medicaid conversion, financial-assistance utilization, and historical collection rates. Pull your own 2026 payer file and check what share of your Marketplace volume shifted from silver-CSR to bronze.
Second, check whether point-of-service collection and financial-assistance screening are calibrated for insured patients. An insured patient with low income and a high deductible may not be identified early if financial-assistance screening is triggered only by uninsured status or account delinquency.
Third, decompose your own July. If your operating margin tracked the national index down, determine whether the driver was OR minutes, mix, or patient responsibility write-offs — because those three have different 2027 trajectories and the seasonal one reverses on its own.
The right 2027 model includes both coverage loss and underinsurance — not one instead of the other.
Sources: Fierce Healthcare, September 17, 2026; Kaufman Hall / Vizient National Hospital Flash Report: July 2026 Data; KFF, "What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles," May 19, 2026 (updated July 15, 2026); KFF, "ACA Marketplace Enrollment is Down in 2026," February 5, 2026.
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