The high-premium, high-OOP, high-subsidy ACA marketplace

 My apologies to long-time subscribers for a a long blogging hiatus. Long story short, volunteer work of various kinds with immigrants has sucked up the bandwidth that used to go into blogging. I will try to do better.

The headline as Open Enrollment kicks off in the ACA marketplace is another 13% increase in average benchmark (second-cheapest silver) premiums. On top of last year’s 26% increase, which hit as the income cap on subsidy eligibility snapped back into place, the increase makes the market that much more unviable for would-be enrollees who don’t qualify for premium subsidies. This year, the income cap on subsidy eligibility, 400% of the Federal Poverty Level (FPL), is $63,840/year for an individual, $86,560 for a two-person household, $109,280 for a family of three, and $132,000 for a family of four.

For some subsidized enrollees, the base premium increases offer potential silver linings. Higher benchmark premiums mean higher subsidies, which can reduce net-of-subsidy premiums for plans priced below the benchmark. That’s mainly bronze plans, but in 21 states, the average lowest-cost gold plan is priced below benchmark. In some states, a full menu of gold plans is priced well below benchmark — mainly in states such as Texas, Illinois, Arkansas and Washington that mandate strict silver loading — that is, pricing silver plans as if all or most silver plan enrollees have incomes below 200% FPL, and so access Cost Sharing Reduction, which raises silver premiums to a roughly platinum level. Assuming that most-to-all silver plan enrollees have incomes below 200% FPL (and so, access actuarial value averaging about 90%) is meant to be a self-fulfilling prophecy, and has proved true in states like Texas that have refused to enact the ACA Medicaid expansion and so have large numbers of enrollees whose incomes would qualify them for Medicaid in expansion states.

Fleshing out the ACA marketplace's alleged phantom enrollees, Part 2

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Your income next year may be $14,000? Can you earn a little more?

It’s time for Part 2 of our close look at Brian Blase’s claims in The Persistent Obamacare Enrollment Fraud and its top-line claim (heavily relied on by CMS) that in 2026, 6.2 million enrollments were “improper.” To reiterate a few big-picture points from Part 1:

1. Blase rhetorically conflates what he’s branded as “the great Obamacare fraud” with enrollments he deems “improper” — that is, enrollments that may show some evidence that the applicant’s estimate of next-year income has been optimized to maximize subsidies. That segue is parroted by CMS in last week’s ASPE brief:

Enrollment that is improper or fraudulent is enrollment by individuals misstating their income to gain access to free plans. Phantom enrollees are unknowingly enrolled in free plans by brokers or auto enrolled. By our estimate, improper, phantom and fraudulent enrollment peaked at 5.6 million people in 2025.

2. The allegations of outright fraud — “phantom” enrollees signed up by brokers, who have no knowledge of their enrollment or no intent to use it— are chiefly based on an analysis of CMS data on ‘enrollees without claims’ (EWOC). This analysis, which ignores the high incidence of short-term enrollment in HealthCare.gov states, driven by year-round enrollment and by the Medicaid unwinding of 2023-2024 — has been effectively rebutted by Matt Fiedler (1, 2) and others. While broker fraud may have given some boost to EWOC, true “phantom” enrollments are small percentage of the enrollments branded as “improper.” As last week’s ASPE brief notes, “In 2025, CMS canceled coverage for 250,000 people enrolled without consent and identified 200,000 unauthorized plan switches.”

Fleshing out the ACA marketplace's alleged phantom enrollees

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If you stop paying for your ACA plan, do you exist?

Now cometh Brian Blase and his colleagues from the right-wing Paragon Health Institute with his third iteration of the so-called “Great Obamacare Enrollment Fraud” (rechristened “The Persistent Obamacare Fraud”) — this time claiming 6.2 million “improper” enrollments .

I wanted to get “fraud” and “improper enrollment” in one sentence, because Blase conceptually segues from outright fraud— people enrolled without their consent, or under false pretenses — to “improper” enrollment, which he defines as enrollments in which the applicant’s future-looking income estimate may have been optimized to her advantage — usually by a broker. The original report deemed all enrollments with allegedly massaged income “fraud.”

Paragon’s core claim, which has not changed substantially since the first iteration of this report in 2024, is that the number of enrollees who estimate 2026 income in the 100-150% FPL range — 10.7 million, or 46% of all enrollees — far exceeds the Census Bureau’s survey-based estimates of the eligible population with income in that range. It’s doubtless true that many enrollees optimize their income estimates, usually at a broker’s direction - -e.g., to get over the 100% FPL eligibility thresholds in the 10 states that have not expanded Medicaid (available to adults with income up to 138% FPL in expansion states), or to get below 150% FPL, the eligibility threshold for the highest level of Cost Sharing Reduction (CSR).

ACA marketplace enrollment erosion update

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Last week, Paige Cunningham at Notus reported* that effectuated ACA marketplace enrollment in April was down 21% from end-of-OEP plan selection totals in the 30 states using HealthCare.gov. For all states, April totals were 17% below end-of-OEP, as attrition was far lower in the 20 states that run their own marketplaces. * About half of the SBMs have somewhat mitigated the effect of the expiration of the enhanced subsidies that were funded only through 2025, offering either supplemental state subsidies, strict silver loading, or Basic Health Programs.

As Charles Gaba has highlighted, the end-of-OEP-to-April drop in 2026 was just about double the 2025 drop of 8.8%. Year-over-year, effectuated enrollment in April is down 13.5%, from 22.2 million in 2025 to 19.2 million this year.

One caveat about terminology that will be relevant going forward: Cunningham reports that 21% of end-of-OEP enrollees in the FFM were “dropped from coverage” after failing to pay their first premium. What she actually appears to have reported, though, is a net difference between total plan selections as of the end of OEP and effectuated enrollment in April. Every month, some people drop coverage and others newly obtain it via individually granted Special Enrollment Periods (SEPs), available after various types of life changes, such as losing employer-sponsored coverage. From February of 2022 to August of last year, SEPs were automatically granted to anyone who reported a qualifying income below 150% FPL. Trump’s CMS cut that automatic SEP off as of August 2025 (a change ratified in the Republican monster bill signed on July 4, 2025) - - and consequently, enrollment dropped from April to December last year for the first time since 2020. (In 2021, a pandemic-induced emergency SEP effectively kept enrollment open to all for more than half the year.)

Visiting Delaney: Come on in and buy your caged loved one some candy

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The chairs are provided by volunteers

Forgive me for going off-topic once more to report what I’ve witnessed at Delaney Hall, the immigration detention center in Newark, NJ, operated by Geo Group. I am a regular visitor to one young man detained at Delaney, as well as a member of the volunteer coalition that provides on-site services to visitors —particularly to mothers of babies and small children whose husbands and partners are detained inside.

My wife and I recently published an op-ed about the rich array of support services for detainees’ families provided immediately outside Delaney Hall by a coalition of volunteer organizations and individuals*. That’s a remarkable tale (I’m speaking as a foot soldier, not an organizer), but my focus here is on the experience of visitors when they go inside Delaney. Their treatment under Geo Group procedures is a mixture of systemic abuse and accommodation that I have often mused over. If the U.S. is transitioning to hard-core fascism (jury’s out, IMO). the visitor experience here is a peculiar halfway house.

The visiting set up run by Geo Group at Delaney is truly bizarre-- it has elements not only of cruelty and incredible inefficiency, but also humanity.

First of all, it's communal. When Essex County ran immigrant detention in Trump 1.0, visits were 1-on-1 behind glass. At Delaney, visits are in what feels like a giant lunchroom, with sometimes over 100 voices reverberating. There are five or six rows of long tables. Detainees sit on benches on one side; visitors face them. Lately the room has sometimes been packed, so that visitors are almost hip to hip (there can be up to four visitors per detainee).

CSR forgone: Long- and short-term changes in the ACA marketplace

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When considering how the most seismic changes in the ACA marketplace’s 13-year history have shaken out, it’s important to keep in mind that the market mainly serves very low-income people. Consider*:

• 64% of all marketplace enrollees in 2026 had income in the 100-200% FPL range. In the U.S. population at large, just 15% were in that income range as of 2024.

• 54% of all marketplace enrollment (12,487,037) in 2026 is in ten states that have refused to enact the ACA Medicaid expansion, where eligibility for marketplace subsidies begins at 100% FPL. In expansion states, Medicaid is available to all adult citizens and qualified noncitizens with income up to 138% FPL.

• More than half of enrollment in nonexpansion states (6,543,435) is in an income bracket (100-138% of the Federal Poverty Level, or FPL) that would qualify those enrollees for Medicaid in expansion states. Those should-be-in-Medicaid enrollees account for 28% of all marketplace enrollment.

• In 2026, 83% of silver plan enrollees nationally had income in the 100-200% FPL range, qualifying them for strong Cost Sharing Reduction (CSR) that raises the actuarial value (AV) of a silver plan to 94% (at incomes up to 150% FPL) or 87% (at income from 150-200% FPL). Nationally, the average AV obtained by silver plan enrollees was 88.6%, justifying the presumption now enforced by several states that silver plans should be priced at a roughly platinum level (90% AV), well above gold (80% AV).

With that low-income skew in mind, I’d like to examine both long-term enrollment trends and shifts in metal selection in 2026, the latter driven mainly (presumably) by expiration of the enhanced ARPA subsidies.

Trends include:

Republicans poised to steal gold from Texans

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To fund Trump’s depraved, immoral and illegal assault on Iran, Axios reports that a Texas sage is proposing a fresh cut to ACA marketplace premiums:

House Budget Committee Chairman Jodey Arrington (R-Texas) is reviving an idea that was considered last year to fund Affordable Care Act payments known as cost-sharing reductions [CSR].

• The Congressional Budget Office previously found the move would lower overall benchmark ACA premiums by 11% but result in 300,000 more uninsured people.

• It would have the effect of cutting the subsidy amount that some enrollees receive, thereby increasing out-of-pocket premium costs, while saving the government over $30 billion.

That proposal would kill silver loading, which would have the most profound effects in Arrington’s Texas, where the pricing of silver plans at platinum levels mandated by statute renders gold plans far cheaper than silver plans and makes free bronze coverage available to almost all enrollees. Before Republicans in Congress seek to end the practice, the 1.7 million Texans in gold plans and likely 800,000-plus in zero-premium bronze plans might want a word.

ACA Marketplace 2026: The downshift to bronze

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Charles Gaba, via a trick that presents itself to the highly motivated, has got hold of the 2026 Public Use Files (PUFs) for the ACA marketplace before they’re officially announced and has parsed them 26 ways. He’s also kindly shared the trick, and so the file.

I want to continue my focus on the degradation of coverage — that is, the shift to lower metal levels, and in particular, the shift away from silver among those eligible for strong Cost Sharing Reduction (CSR), which raises the actuarial value of a silver plan from a baseline of 70% to 94% (at incomes up to 150% of the Federal Poverty level) or 87% (for those in the 150-200% FPL) range.*

For starters, here is the metal level breakdown for all states in 2025 vs. 2026.

Accelerating a multi-year trend, silver selection fell sharply. a shift modestly offset by an increase in gold selection, as three states (Washington, Arkansas, Illinois) newly implemented strict silver loading in 2026, rendering gold plans less expensive than silver (in Illinois and Arkansas, 31% of enrollees selected gold plans, and in Washington, 51% selected gold).

Triage for U.S. healthcare: Families USA's Stop the Bleed campaign

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In the United States today, as rising healthcare costs for individuals and government alike approach a crisis point, major systemic change enacted by legislation feels utopian. Behemoths stalk the healthcare landscape: Mega-insurers control major PBMs, large numbers of physician practices, and tech tools to maximize billing; hospital systems dominate their regions; pharmaceuticals maximize pricing power over fractured payers; private equity firms roll up major physician specialist practices within target markets and dominate target services like hospice and dialysis.

These powerful actors deploy our corrupt campaign financing rules to deter elected officials from both parties from enacting legislation that would fundamentally threaten their current revenue sources. A single-payer system, or a strong public option available to all, or a national system of all-payer rate-setting, are not likely to happen this side of revolution (including, on the hopeful side, political revolution).

In tacit acknowledgment of those facts, Families USA has launched Stop the Bleed — almost literally a triage campaign to provide some cost relief to the people of this country. The campaign invites healthcare advocates — and anyone who wants to sign up — to ask candidates for electoral office from both parties and at any level what they propose to do to control healthcare costs.

In GetCoveredNJ, a shift toward bronze plans in 2026

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This year's NJ marketplace has feet of bronze

GetCoveredNJ, New Jersey’s state ACA marketplace, has released its final enrollment snapshot for OEP 2026. Enrollment is down less than 1% from OEP 2025, but attrition when people have to make their first premium payments — and, if they get that far, sustain higher payments year-long — will probably drop average monthly enrollment well below the 2025 level. * In particular, the 211,289 renewing enrollees who passively auto-re-enrolled may react to sticker shock. (Conversely, a very sharp spike in active re-enrollments, from 85,177 in 2025 to 219,933 in 2026, points to a large potential well of resilience — people who noted the premium spikes and made a conscious choice.)

As the enrollment report emphasizes, premiums rose sharply for most enrollees in 2026, whether or not they lost subsidy eligibility. In 2025, 44% of all enrollees had paid less than $10/month in premiums; this year, just 10% will. Last year, 28% of enrollees paid more than $100/month; this year, 44% have crossed that threshold. This year, 18% of enrollees obtained no federal subsidy ; last year, just 9% went without APTC. (A third of those who are ineligible for federal subsidies obtained smaller state supplemental subsidies, available at incomes up to 600% FPL.) See Gaba for a finer-grained breakdown of net-of-subsidy premiums paid.

I want to focus here on coverage degradation in 2026 — a down-shifting in metal level. In New Jersey, that means almost entirely a switch from silver plans to bronze, because in NJ, gold plans are effectively unaffordable, chosen by just 1% of enrollees in 2025 and 2026 alike. The Jersey marketplace has always been dominated by silver plans, but in 2026 silver selection dropped to 74.1%, down from 83.3% in 2025.