To silver-load or not: Arkansas vs. New Jersey marketplace, 2026

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Does the NJ marketplace need a Huckabee-sting?

The looming expiration of the enhanced Premium Tax Credits in the ACA marketplace (ePTC) increases the salience of the extent to which different states encourage or enforce strict “premium alignment,” A.K.A. silver loading, the pricing of the full value of Cost Sharing Reduction (CSR) into silver plans.

Here, we’ll contrast current plan offerings in a state marketplace with some of the most extreme silver loading effects, Arkansas, with a state where the effects are among the weakest, New Jersey.

If you are unfamiliar with how silver loading works or why it exists, see the explanation at bottom.

To defend against the looming expiration of the enhanced ACA subsidies funded only through 2025, Arkansas implemented the nation’s strictest “premium alignment,” requiring insurers to price silver at 1.46 times what it would be priced at the baseline silver actuarial value of 70%. That is, Arkansas requires insurers to price silver plans as if all silver plan enrollees have income under 200% FPL and so obtain plans with actuarial value of 94% (the AV of CSR-enhanced silver for enrollees with income up to150% FPL) or 87% (silver AV for enrollees in the 150-200% FPL income bracket) — an average AV of 91%. For a convoluted tale of how Arkansas arrived at this point, see Charles Gaba.

Pricing silver as if all enrollees have income under 200% FPL is meant to be a self-fulfilling prophecy. A “CSR factor” like Arkansas’ ensures that gold plans will be cheaper than silver plans with the same provider network, making silver plans an illogical choice for enrollees with income over 200% FPL, since gold plans have a higher AV than silver for enrollees above that income threshold. That assumption has been borne out in the Texas marketplace, where in 2025, just 1% of the state’s 1.9 million silver plan enrollees had income over 200% FPL.* In 2025, 78% of silver plan enrollees in Arkansas obtained 94% AV or 87% AV. The average weighted AV for silver plan enrollees in the state was 86.8%. It’s not a great leap to assume average silver plan AV of 91% under the current pricing regime.

Thanks to this pricing formula for silver plans, Arkansas has the nation’s widest premium spread between the average lowest-cost bronze plan and the average benchmark (second cheapest) silver plan. On average, the premium for the lowest-cost bronze plan in Arkansas is just 57.8% of the benchmark silver premium. Gold coverage in Arkansas is also very cheap, averaging just 83.6% of the benchmark. On that front, Arkansas is tied with Pennsylvania for fourth-lowest in the nation.

Mitigating the Medicaid cuts

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Look for the helpers

The enactment of the Republicans’ monstrous budget bill in one sense sets politics and policy at odds, at least for Democrats. Annie Karni, congressional report for The New York Times, frames a political problem for Dems:

A challenge for Ds who expect the passage of this bill to help them win elections is that it may take a while for people to feel the full negative effects. Rs front loaded some temporary tax cuts for working people and backloaded cuts to Medicaid to hit after the midterms.

As KFF’s Larry Levitt points out in response, funding cuts and some impediments to enrollment in the ACA’s private-plan marketplace kick in immediately or almost immediately, i.e., for OEP 2026, beginning Nov. 1 this year (and Charles Gaba has tallied provisions in both Medicaid and marketplace that will take effect before the midterms). That said, Republicans will of course exploit the time lag, which extends to other benefit cuts as well (SNAP, student loans, energy credits), using it to add plausibility to their claims that, as MAGA go-along Tom Kean Jr. (NJ-7) boasted, “we protected Medicaid for every intended beneficiary in New Jersey and across the country.” That is, the bill does not change Medicaid eligibility for anyone (except various classes of lawfully present noncitizens, who are just human waste in Republican parlance). Instead, Republicans set up a thicket of administrative enrollment impediments and cuts to state funding (mostly delayed) that will increase the uninsured population by some 12 million by CBO’s estimate (with another 4 million losing coverage due to Republicans’ refusal to extend the enhanced ACA marketplace subsidies funded through 2025*). If enrollment reductions on that scale don’t happen — as many Republicans claim — neither will the cuts to federal spending that help fund the bill’s gargantuan tax cuts.

All that said, I’d like to consider Democrats’ alleged political “challenge” from the opposite end of the telescope. To what extent can Democrats in state government — and, more speculatively, in Congress — mitigate the coverage and funding losses? Administrative barriers can be erected with steel or Styrofoam — though Trump’s CMS, led by people whose chief passion in life is to ensure that someone somewhere doesn’t get a benefit to which they’re not technically entitled**— will doubtless work to insist on steel. If Democrats take the House, they may be able to delay or reduce some spending cuts — the annual ratchet-down of the provider tax safe harbor, for example, strikes me as the kind of thing Congress is prone to pause.

Will the ACA reduce the disability rolls?

Two years ago, I was riveted by TNR reporter Alec MacGillis' chat with a woman on line for a free REM medical clinic in rural Tennessee. Notwithstanding that she knew nothing about the ACA, she offered a stunning instant analysis, once the basics were described to her, of one likely economic effect:

..it it was hard to find visitors to the clinic who would not benefit directly from the law. Barbara Hickey, 54, is a diabetic who lost her insurance five years ago when her husband was injured at his job making fiberglass pipes. She gets discounted diabetic medication from a charity, but came to the clinic to ask a doctor about blood in her urine.

Under the law, she would qualify for Medicaid. Her eyebrows shot up as the law was described to her. "If they put that law into effect, a lot of people won't need disability," she said. "A lot of people go onto disability because they can't afford health insurance."

Lo, Ms. Hickey was a prophet (perhaps). In Arkansas, which has sliced its uninsured rate almost in half since ACA enactment, mainly by enrolling nearly 200,000 Arkansans in the state's "private option" Medicaid alternative, disability claims seem to be dropping.* Modern Healthcare's Paul Demko reports:**

Red state attitudes toward the ACA: like America's, but more so

Update, 4/25:  see next post re the high rate of pre-existing conditions reported by respondents to this poll.

A New York Times/Kaiser Family Foundation poll released yesterday probes perceptions of the Affordable Care Act in four red states, Arkansas, Kentucky, Louisiana and North Carolina. * In all of these states, Obama's approval rating is in the 30s, and the ACA is also deep underwater, with approval/disapproval percentages ranging from 29/62  in Arizona to 38/54 in North Carolina.*

Those overall judgments, stoked by five years of relentless Republican denunciations and a barrage of negative advertising in recent months, are stark.  And yet, the underlying attitudes revealed in the poll's internals are strikingly congruent in key respects to the attitudes toward prospective healthcare reform recorded nationally in a Kaiser poll conducted in December 2008, when approval for a president-elect who had campaigned on a national healthcare overhaul was sky-high. 

In both polls, majorities opposed simply maintaining the pre-ACA status quo -- doing little or nothing to expand coverage in 2008, repealing the ACA today. In both, majorities favored government action to make health insurance available to people who could not get it from their employers. In both, majorities supported expanding Medicaid.  Yet in both, majorities rejected the notion that it was the federal government's responsibility to make affordable healthcare coverage available to all Americans.

Obamacare to be repealed and replaced in 2017...

In at least one state, that is.

Almost everything that Republicans who profess to want to reduce the ranks of the uninsured on the ACA's scale say they want to do can be done via state waivers effective 2017.

Here is a summary of ACA Sec. 1332, Waiver for State innovation, from an ACA outline posted on the Democratic Policy and Communication Center website:

Beginning in 2017, allows States to apply for a waiver for up to 5 years of requirements relating to qualified health plans, Exchanges, cost-sharing reductions, tax credits, the individual responsibility requirement, and shared responsibility for employers. Requires States to enact a law and to comply with regulations that ensure transparency. Requires the Secretary to provide to a State the aggregate amount of tax credits and cost-sharing reductions that would have been paid to residents of the State in the absence of a waiver. Requires the Secretary to determine that the State plan for a waiver will provide coverage that is at least as comprehensive and affordable, to at least a comparable number of residents, as this title would provide; and that it will not increase the Federal deficit.

HHS guidelines for privatized Medicaid expansion

The Department of Health and Human Services issued a FAQ on Friday regarding its receptivity to state proposals, like the one floated by Arkansas, to use the federal funds for Medicaid expansion through the ACA to offer private insurance through the ACA exchanges to Medicaid-eligibles.

HHS points out that outside the ACA expansion, states already can use Medicaid funds to buy private coverage  (mostly through private group health plans) for Medicaid recipients, provided that the plans are deemed "cost effective" -- that is, "that Medicaid’s premium payment to private plans plus the cost of additional services and cost sharing assistance that would be required would be comparable to what it would otherwise pay for the same services."

The new departure would be using federal money to buy qualified health plans on the new ACA exchanges for those covered by the ACA's Medicaid expansion. It's important to note the context in which HHS will consider "demonstration projects" of this sort: it will do so to "inform policy for the State Innovation Waivers that start in 2017."  In 2017, states can apply to "pursue their own innovative strategies to ensure their residents have access to high quality, affordable health insurance" providing the proposed plan