CMS spin on the ACA marketplace, threaded through the Washington Post

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To have or have not..or have a lot less

My last post delved into CMS’s spin on the expiring enhanced ACA subsidies — that is, the agency’s focus on a) the comparatively modest increase in subsidized enrollees’ premiums for the lowest-cost bronze plan available in 2026 (up a mere 35%, compared to the 114% increase for benchmark silver calculated by KFF) and b) on a relative reduction in the lowest-cost bronze premium compared to 2020 (seven OEPs ago!).

I am sorry to see this distorted frame adopted in the Washington Post by a veteran ACA reporter, Paige Cunningham. The article is not factually inaccurate (though I can’t quite make some of the premium quotes work), but it downplays the impact of expiration of the enhanced subsidies on those who remain subsidized.

Here are the select facts Cunningham reports through the CMS filter:

1. Most people with low incomes are still heavily subsidized

The vast majority of people will still get subsidies, and there are limits on how much of their annual income they can spend on a plan.

To illustrate this, let’s rewind to 2020 — before the extra subsidies started — using a cost calculator by KFF, a nonpartisan health policy group, as a guide.

A person earning $22,000 annually could buy a subsidized, silver-level plan for $63 a month. Next year, it would cost $80.

Say this person’s earnings increase to $45,000. In 2020, they could get a silver plan for $303 a month. Next year, it would cost $387.

This is a point the Trump administration is stressing: Americans with low to middle incomes are not the ones hit with eye-popping price hikes. The Centers for Medicare and Medicaid Services said this week that the average marketplace premium for those eligible for subsidies will be $50 for the lowest-cost plan.

Let’s consider the actual plight of the person earning $22,000 in 2026. A benchmark silver plan will actually cost $66/month (not $80, but never mind*). The salient comparison is not with 2020 but with 2025 — when this same person would pay $0 for a benchmark silver plan (as she will in 2026 if the enhanced subsidies are renewed). At this income level, a silver plan includes Cost Sharing Reduction (CSR) that boosts the Actuarial Value at 94%. While bronze plans will still likely be available for zero premium to enrollees at this income level, the bronze AV is roughly 60%. Many of the 9 million-odd current enrollees in 94% AV silver will downshift to bronze. That usually means swapping a plan with an average deductible under $100 and an out-of-pocket maximum below $2,000 for a plan with a deductible over $7,000** and an OOP max approaching the highest allowable, $10,600.

As for the person with an income of $45,000, benchmark silver in 2026 will cost $359/month — vs. $206/month if the enhanced subsidies are renewed. Who cares what benchmark silver would have cost in 2020, when the percentage of income required for a benchmark silver plan was slightly lower than in 2026? (The “applicable percentages were somewhat lower in 2020 than they are for 2026, thanks to a deliberate decision by Trump’s CMS to adopt an inflation calculation that increases them.) Enrollment in 2020 was less than 50% of enrollment in 2025 — because millions of people in need of insurance found the subsidized premiums too expensive.

Contra Cunningham, subsidy-eligible people seeking marketplace coverage will indeed be hit with “eye-popping price hikes.” One particular pain point is at incomes just below 200% FPL, the ceiling for strong CSR, which attaches to silver plans only. For a single person with an income of $30,000, the benchmark silver premium sans enhanced subsidies will be $155/month in 2026, vs. $42/month if the enhanced subsides are renewed.

This underplaying of the impact of the pending enhanced subsidy expiration on still-subsidized enrollees also somewhat skews Cunningham’s otherwise accurate account of the plight of those who go over the subsidy cliff and lose subsidy eligibility:

2. It’s higher-income enrollees facing massive sticker shock

…people in this group [income over 400% FPL, the cap for subsidy eligibility] could see enormous strains on their personal finances as the cap ends in 2026. They have lost all protection against premium increases. I talked to people this week whose monthly premium payments will double or even triple if they stay on their plan. Many of them are in their 50s and early 60s and are seeing some of the highest premiums because insurers can charge older people more.

All true — but as we have seen, those still eligible for subsidies also will see their monthly premiums “double or even triple.” Current enrollees who will remain subsidy-eligible outnumber those who will lose subsidy eligibility by more than ten to one. (In OEP 2025, 22.4 million enrollees were subsidized, and 1.6 million enrollees reported an income over 400% FPL — not all of whom gained subsidies.) The plight of people with income modestly over the subsidy limit is politically charged — in fact it was Republicans’ chief cudgel against the ACA until the American Rescue Plan Act removed the income cap on subsidy eligibility. And it’s genuinely bad — the unaffordability of coverage for many with income over 400% FPL undercut the promise of “affordable care” inherent in the ACA’s name. But the increases for those who remain subsidy-eligible will have more collective impact.

Cunningham also uncritically relays a false talking point from the charlatan who now heads CMS:

“There can be a lot of hair-pulling and mudslinging, but … that’s not the issue,” CMS Administrator Mehmet Oz told reporters this week. “The big issue is the fundamental flaws within the ACA.”

Oz was referring to how the law has not curbed the overall cost of health insurance, which continues to go up. While the ACA dramatically expanded insurance access to millions of Americans, it relied primarily on government spending to help people get coverage rather than making health care less expensive.

While standing up a subsidized individual health insurance market was probably not the best way to control healthcare costs, premiums in the ACA marketplace rose considerably less than in employer-sponsored insurance from 2019 through 2025 (following steep increases triggered by a genuine correction in 2017 and Republican-induced political turmoil in 2018). (See Table 17 in the current NHEA.***)More broadly, the ACA as a whole probably deserves partial credit for a slowdown in healthcare spending from about 2013-2023 -- mostly thanks to cuts in payments to Medicare Advantage plans and hospitals, and perhaps to a modest degree to an array of experimental programs incentivizing coordinated care. Our healthcare system remains dysfunctionally profit-oriented, but the claim that the ACA marketplace is more flawed than the commercial market generally — or a particularly “unsustainable” part of our patchwork health insurance landscape — is a Republican myth.

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* Comparisons here are somewhat skewed by an annual inflation adjustment for the Federal Poverty Level (FPL), which determines subsidy size. In OEP 2026, $22,000 is 141% FPL. In 2020, that same income was 172% FPL, and a person at that FPL level in 2020 would have paid about 5.3% of income for benchmark silver, or $97/month. In 2020 141% FPL was $17,992 for an individual, who would have paid about 3.6% of income — $54/month for benchmark silver.

** There are some bronze plans with $0 medical deductibles, but the AV has to be met somehow — e.g., with a $4,000 drug deductible or a $3,000 hospital copay.

*** According to the NHEA, from 2018-2023 (the last year for which data is available), premiums for single-person employer-sponsored insurance (ESI) rose 29%, from $5,678 to $7,326, while “direct purchase” premiums (in the individual market) rose 13%, from $4,827 to $5,451. According to KFF, from 2023 to 2025, ESI premiums rose 11%, while ACA marketplace premiums rose 9% (my tweet here links to the relevant KFF reports and tables). As to whether premiums spike as much in ESI in 2026 as they have for the marketplace — we’ll see, e.g. when KFF releases its next report on employer-sponsored health benefits next fall.

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