The Unaffordability of Affordable Care Act Health Insurance Plans

BACKGROUND: The Affordable Care Act (ACA) aimed to simplify plan choice and provide affordable health insurance. However, the complexity and cost-sharing features of ACA plans may undermine its goals. OBJECTIVES: To examine the affordability and choice set of all individual ACA health insurance plans, and the cost implications for taxpayers. DESIGN: Cross-sectional study. SUBJECTS: ACA marketplace plans nationwide. MEASURES: We analyzed choice set, total premiums, and total deductibles for all plans in all US ACA markets using 2023 HIX Compare data, Small Area Health Insurance Estimates, and American Community Survey data. We evaluated affordability for persons with incomes above 400% of the Federal Poverty Line (FPL), for whom ACA premium tax subsidies are set to expire, defining premiums ≥10% of annual income as unaffordable. RESULTS: In 97% of US counties, ACA consumers were offered >= 25 ACA plans, and 40% of counties offered >127 plans. Presubsidy, the median (IQR) Bronze plan premium was $4160 ($3636-4866), with a median (IQR) deductible of $7500 ($5300-$9700). The median (IQR) Silver plan premium was $5057 ($4430-5892), with a median (IQR) deductible of $2000 ($0-6800). Among persons with income at 400% of FPL, 98.6% of markets had ≥75% of their plans with unaffordable premiums for a 2-adult household, and 97.0% of markets had ≥75% of plans with unaffordable premiums for a 50-year-old individual should subsidies expire. CONCLUSIONS: Excessive plan choice creates significant challenges for consumers in selecting appropriate coverage. The magnitude of premiums and deductibles is unsustainable due to the financial burdens they place on the individual ACA consumer and/or the American taxpayer.