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| Between CMS's Scylla and Charybdis |
There is a throughline in Republican proposals, both legislative and regulatory, to “reform” health insurance, particularly in the ACA marketplace. Consistently, Republicans propose to reduce premiums paid by government and (sometimes) enrollees by
increasing out-of-pocket exposure;
narrowing provider networks; and
increasing risk and uncertainty for enrollees.
CMS’s just-published 2027 Notice of Benefit and Payment Parameters (NBPP) for the ACA marketplace, a multi-part rule published annually, advances these goals on multiple fronts. The NBPP would expand access to catastrophic plans (available only without subsidy); degrade actuarial value in catastrophic and bronze plans by allowing them to add 30% to the highest allowable annual out-of-pocket maximum (to an eye-watering $15,400 per individual in 2027); deliberately draw healthier enrollees into the catastrophic market, worsening the main ACA risk pool; weaken network adequacy requirements; financially penalize states for incorporating their own coverage mandates in Essential Health Benefits (EHBJ) standards; and allow QHP certification of non-network plans.
I want to focus here on the certification of non-network plans, because it is a first swipe at the longstanding Republican goal of directing premium subsidies to plans reminiscent of the pre-ACA marketplace. In this case, CMS proposes to expose marketplace enrollees to out-of-pocket costs with no effective cap and to the balance billing that’s now mostly prohibited against enrollees in minimum essential coverage provided by marketplace or employer-sponsored plans.
