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.
Also, for those whose income hasn’t kept up with inflation, the Federal Poverty Level has risen rapidly in the post-pandemic high-inflation years. If your income is static, your income’s percentage of FPL goes down, and your subsidy goes up accordingly (and may slip you into a higher CSR bracket).
Conversely, out-of-pocket costs at each metal level continue their relentless rise — in the form of deductibles, annual out-of-pocket maximums (now topping out at a wealth-stripping $12,000/individual, $24,000/family), and copays. And though this is only anecdotal, I have also seen complaints reflecting a long term trend in which narrow-network insurers enter a market and undercut insurers with more robust networks — often Blue Cross/Blue Shield plans. (The Blues sometimes also undercut themselves with new narrow network options, or by raising premiums on plans in robust networks more than for their narrow-network options). Further, in high-inflation years, while FPL rises, so does the percentage of income required to purchase a benchmark plan. Last year, the Trump administration deliberately exacerbated that cost increase by changing the inflation formula that sets the “applicable percentages” of income required to buy a benchmark silver plan at each income level. The Trump CMS mandated that the premium inflation calculation include individual market premiums — which team Trump and the Republican Congress have worked relentlessly to inflate by various means, thereby further inflating the applicable percentages. This year, enrollees in the highest subsidy-eligible income bracket (300-400% FPL) will pay 10.22% of income for a benchmark silver plan. In Plan Year 2025, following a low-inflation year, they paid 8.65% of income (the lowest ever).
The higher applicable percentages, which carry through all income brackets, are likely to accelerate the collapse of silver plan selection at incomes below 200% FPL — the threshold below which Cost Sharing Reduction, which attaches only to silver plans, makes silver plans roughly platinum-equivalent, with an actuarial value well above that of gold plans. As I noted in April, in states using HealthCare.gov, silver selection at incomes below 150% FPL dropped from 89% in 2017 to 74% in 2025 — and to 54% in 2026.
Enrollees in the next-lowest income bracket, 150-200% FPL, mostly no longer consider silver plans affordable. Just 35% of enrollees in this bracket selected silver plans in 2026, compared to 83% in 2017. At 200% FPL — $31,920/year for a single adult — benchmark silver now costs $180/month. That’s 6.8% of gross income — and about 8.5% of net income.
A snapshot of select current options in Miami, the nation’s largest ACA market, shows the extent to which the marketplace has evolved to squeeze out silver plans at all but the lowest incomes. Because BCBS Florida is a dominant brand, I have included in the snapshot two low-cost bronze plans (one of them Blue) that offer a range of services outside the deductible (prices shown are not subject to the deductible). The gold and silver plans are the lowest-cost plans in their metal levels.
The most salient tradeoff in favor of high-CSR silver plans, in my view, is the out-of-pocket (OOP) max — which, although the highest allowable for CSR plans at this level, is about 1/3 that of the bronze and silver alternatives. Again, though, $167/month is a lot to pay at this income, and most people who don’t expect high medical costs are going to accept the higher out-of-pocket exposure.
In Miami, Oscar is the only insurer offering low-cost gold plans, priced below benchmark. As in Philadelphia, the dominant insurer (there, Independence Blue Cross) does not off low-cost gold coverage. That increases the salience of bronze plans that offer significant services outside the deductible. For our 40 year-old Miamian with the $31k income, two high-deductible bronze plans are available for zero premium.
In sum, many subsidy-eligible prospective marketplace enrollees have access to low-premium plans that offer at least some coverage — but most are exposed to very high out-of-pocket costs. Most are also exposed to a dizzying array of plan choices that require very complicated bets as to how much out-of-pocket cost one is likely to incur, and of what kind.
Next up: some snapshots of employer-sponsored coverage at low incomes. They aren’t pretty.
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