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How ACA Marketplace Premiums Are Changing by County in 2019

Premiums for ACA Marketplace benchmark silver plans are decreasing on average across the U.S. in 2019. However, premium changes vary widely by location and by metal level, including premium increases in a number of counties and plans. Additionally, the amount an exchange enrollee actually pays in premiums depends largely on their income – as most enrollees receive significant premium subsidies – and the difference in cost between the benchmark (second-lowest silver plan) and the premium for the plan they choose.

ACA premiums are flat or falling in many areas of the U.S. This analysis of how marketplace premiums are changing in 2019 has interactive maps w/ county-level data illustrating changes for the lowest-cost bronze, silver & gold plans across the country.

We analyzed premium data from insurer rate filings to state regulators and healthcare.gov to see how premiums are changing at the county level both before and after subsidies in 2019. The map below illustrates changes in premiums for the lowest-cost bronze, silver, and gold plans by county. Results are shown for a 40-year-old paying the full premium and for a 40-year old with an income of $20,000 (165% of poverty), $25,000 (206% of poverty), $30,000 (247% of poverty), $35,000 (288% of poverty), and $40,000 (329% of poverty), who would be eligible for a premium tax credit.

Change in Lowest-Cost Metal Plan Before and After Tax Credit, 2018-20191

Nationally, the average unsubsidized premium for the lowest-cost bronze plan is decreasing by 0.3% from 2018 to 2019, the average unsubsidized lowest-cost silver premium is decreasing by 1%, and the average unsubsidized lowest-cost gold plan is decreasing by 2% (Table 1).

Table 1: Change in the Average Lowest-Cost Premium by Metal Level Before Tax Credit, 2018-2019 for a 40-year-old
Change in Lowest Cost Bronze Premium (%) -$1 (-0.3%)
Change in Lowest Cost Silver Premium (%) -$4 (-1%)
Change in Lowest Cost Gold Premium (%) -$12 (-2%)
Change in Lowest Cost Benchmark Premium (%) -$4 (-1%)
 SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings.

Unsubsidized premiums for benchmark silver plans (which are the basis for determining the amount of financial assistance an enrollee receives) are dropping by 1% on average, which has varying effects on the average changes in premiums at different metal tiers:

  • Unsubsidized premiums for benchmark silver plans are decreasing more steeply (1% decrease) than unsubsidized premiums for low-cost bronze plans (0.3% decrease). This means that premium tax credits will generally cover less of the total premium for a low-cost bronze plan in 2019 and bronze premium payments (after tax credits) will go up for many subsidized enrollees. Nonetheless, there are more counties in 2019 than in 2018 where very low-income enrollees will have the option of a free bronze plan after tax credits are applied. Therefore, average bronze premium payments for very low-income enrollees are dropping a bit after tax credits.
  • Unsubsidized premiums for benchmark silver plans are decreasing by roughly the same amount as unsubsidized premiums for low-cost silver plans (1% decrease). This means that average premium tax credits cover a similar portion of low-cost silver premiums as they did in 2018, and silver premium payments for the average subsidized enrollee are going up only slightly. (The 1-3% increase shown in Table 2 mostly reflects the slight increase in enrollee premium contributions due to changes in the federal poverty level and indexed premium caps).
  • Unsubsidized premiums for benchmark silver plans are decreasing by less than unsubsidized premiums for low-cost gold plans (2% decrease). This means that average premium tax credits will cover more of the total premium for a low-cost gold plan for many enrollees. Consumers who receive premium tax credits may be able to pay less for a gold plan than they did in 2018 (Table 2). Higher-income enrollees purchasing gold plans have slightly higher average premium payments (after tax credits) due largely to the aforementioned changes in the federal poverty level and premium caps.
Table 2: Change in the Average Lowest-Cost Premium by Metal Level After Tax Credit, 2018-2019
40-year-old with $20,000 income (165% of poverty)
Change in Lowest Cost Bronze Premium (%) -$0.02 (-0.4%)
Change in Lowest Cost Silver Premium (%) +$1 (+1%)
Change in Lowest Cost Gold Premium (%) -$5 (-4%)
40-year-old with $25,000 income (206% of poverty)
Change in Lowest Cost Bronze Premium (%) +$3 (+13%)
Change in Lowest Cost Silver Premium (%) +$3 (+2%)
Change in Lowest Cost Gold Premium (%) -$4 (-2%)
40-year-old with $30,000 income (247% of poverty)
Change in Lowest Cost Bronze Premium (%) +$6 (+9%)
Change in Lowest Cost Silver Premium (%) +$5 (+3%)
Change in Lowest Cost Gold Premium (%) -$3 (-1%)
40-year-old with $35,000 income (288% of poverty)
Change in Lowest Cost Bronze Premium (%) +$9 (+7%)
Change in Lowest Cost Silver Premium (%) +$7 (+3%)
Change in Lowest Cost Gold Premium (%) -$1 (-0.27%)
40-year-old with $40,000 income (329% of poverty)
Change in Lowest Cost Bronze Premium (%) +$12 (+7%)
Change in Lowest Cost Silver Premium (%) +$10 (+3%)
Change in Lowest Cost Gold Premium (%) +$2 (+1%)
SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings.
NOTE: The premium change is calculated as the difference between the average premium in 2018 and 2019, weighted by 2018 plan selections.

Whether enrollees will see their premium payments increase or decrease for 2019 will depend on how benchmark premiums are changing and how premiums for plans at their preferred metal level are changing in their county. For example, a 40-year-old individual making $35,000 (288% of poverty) and eligible for a tax credit will on average pay $9 per month more in 2019 for their share of the premium for the lowest-cost bronze plan, $7 more for the lowest-cost silver plan, and $1 less for the lowest-cost gold plan.

As was the case in 2018, unsubsidized silver plans in some counties continue to be priced relatively high (and even cost more than unsubsidized gold plans in parts of the country) because insurers generally loaded the cost from the termination of federal cost-sharing reduction payments entirely onto the silver tier (a practice sometimes called “silver loading”). The relatively higher price for silver plans due to silver loading means subsidy-eligible Marketplace enrollees will continue to receive relatively large premium tax credits, although these tax credits will be smaller than in 2018 for many consumers based on decreases in the underlying benchmark silver premiums. These subsidies continue to make gold plans more easily attainable and make bronze plans cheaper (or even more likely to be available for $0) than before cost-sharing reduction payments were terminated.

Subsidized premiums for bronze plans may be particularly attractive to many people eligible for premium tax credits (Table 3). For example, the tax credit for a 40-year-old individual making $25,000 covers the full cost of the premium for the lowest-cost bronze plan in 64% of counties (2,014 out of 3,142 counties in the U.S.). This is an increase from 2018, when the tax credit covered the full cost of the lowest-cost bronze plan in 53% of counties (1,679 counties).

However, even if silver premiums are higher than bronze premiums it is still important for low-income enrollees to consider the significant cost-sharing assistance that is only available if they enroll in a silver plan. In order to qualify for a plan with a cost-sharing reduction (CSR), low-income enrollees must sign up for a silver plan. CSR plans lower the amount an enrollee spends out-of-pocket by setting a lower out-of-pocket maximum, which also translates to lower deductibles, copayments, and coinsurance. For example, a single individual making between 100-200% of the poverty level can qualify for a silver plan with an out-of-pocket maximum of no more than $2,600, and the deductible would likely be significantly lower than that. If the same individual instead signs up for a bronze plan, the out-of-pocket maximum and deductible could be upwards to $7,900. If this person is sick or expects to have high health spending, it may be better to pay a relatively higher premium for a silver plan even if a bronze plan is available for a $0 premium.

Table 3: Number of Counties Where an Individual’s Tax Credit Covers the Full Premium of the Lowest-Cost Bronze Plan, for a 40-year-old
Example Age and Income 2018 2019
40-year-old with $20,000 income (165% of poverty) 2,434 2,532
40-year-old with $25,000 income (206% of poverty) 1,679 2,014
40-year-old with $30,000 income (247% of poverty) 488 659
40-year-old with $35,000 income (288% of poverty) 169 417
40-year old with $40,000 income (329% of poverty) 104 120
SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings.
NOTE: The total number of counties in 2018 was 3,143 but is 3,142 in 2019 because Bedford city county, Virginia, was incorporated into Bedford county.
These counts do not include plans in New York, Minnesota, or Alaska where enrollees may be eligible for a Basic Health Program or Medicaid.

The map below shows where an individual’s tax credit covers the full premium of the lowest-cost bronze plan for a 40-year-old with an income of $20,000 (165% of poverty), $25,000 (206% of poverty), $30,000 (247% of poverty), $35,000 (288% of poverty), and $40,000 (329% of poverty).

Counties Where the Lowest-Cost Bronze Plan Premium Costs Zero Dollars After the Tax Credit in 2019

In 2019, the unsubsidized lowest-cost gold premium is lower than the unsubsidized lowest-cost silver premium in 25% of counties (792 counties), compared to 15% of counties (478 counties) in 2018. For subsidized enrollees, a gold plan may actually be available at no cost after tax credits are applied (Table 4). For example, the tax credit for a 40-year-old individual making $25,000 covers the full cost of the premium for the lowest-cost gold plan in 153 counties (out of 3,142 counties in the U.S.). This is an increase from 2018, when the tax credit covered the full cost of the lowest-cost gold plan in 33 counties.

Table 4: Number of Counties Where an Individual’s Tax Credit Covers the Full Premium of the Lowest-Cost Gold Plan, for a 40-year-old
Example Age and Income 2018 2019
40-year-old with $20,000 income (165% of poverty) 132 411
40-year-old with $25,000 income (206% of poverty) 33 153
40-year-old with $30,000 income (247% of poverty) 6 39
40-year-old with $35,000 income (288% of poverty) 5 12
40-year old with $40,000 income (329% of poverty) 0 12
SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings.
NOTE: The total number of counties in 2018 was 3,143 but is 3,142 in 2019 because Bedford city county, Virginia, was incorporated into Bedford county.

These counts do not include plans in New York, Minnesota, or Alaska where enrollees may be eligible for a Basic Health Program or Medicaid.

The map below shows counties where the unsubsidized premium for the lowest-cost gold plan has a lower or comparable premium to the lowest-cost silver plan in 2019, before tax credits are applied.

Counties Where the Lowest-Cost Gold Plan Costs Less than the Lowest-Cost Silver Plan, Before Tax Credits

Discussion

With news of average benchmark premiums dropping a bit on average in 2019, consumers may expect to pay less for any plan on the ACA Marketplaces. In reality, there is wide variation in premium changes, including premium increases for many consumers. What a given consumer actually pays depends on income, location, and differences in pricing between their plan and the benchmark silver plan. For consumers to know how much they will pay, they must return to Healthcare.gov or their state’s exchange each year and carefully consider their options.

As silver plans in 2019 continue to have relatively higher costs compared to bronze plans, subsidized enrollees in many parts of the country will qualify for “free” (zero-premium) bronze plans. Most insurers are continuing to load the cost of offering reduced cost sharing plans onto silver premiums. The benchmark (second-lowest cost) silver plan is the basis for determining the amount of financial assistance consumers receive. When silver premiums are high in comparison to bronze plans, the large tax credit may cover all or most of the cost of a bronze plan. While “free” bronze or gold plans will be available to subsidized enrollees in more counties in 2019 it is still important for low-income enrollees, particularly those in need of more medical care, to consider the significant cost-sharing assistance that is only available if they enroll in a silver plan.

Although CMS discontinued payments to insurers for reducing cost sharing for lower-income enrollees, insurers remain obliged to provide reduced cost sharing policies to eligible Marketplace enrollees. Silver plans with reduced cost sharing generally have higher actuarial values than gold plans for enrollees with incomes below 200% of poverty. Low-income consumers will need to consider whether it makes sense to purchase a metal level other than silver, as a lower premium plan may come with significantly higher deductibles, copays, or coinsurance.

Methods

We analyzed data from the 2018 and 2019 Individual Market Medical files to determine premiums and the benchmark amounts to calculate premium tax credits for the scenarios presented.  These files are available at data.healthcare.gov.  Premiums for the 12 state-based marketplaces are from a review of insurer rate filings and state plan finders. For most states running their own exchange, premiums presented in this analysis are at the rating area level. Where premiums and benchmark amounts varied by zip code within a county, the benchmark for the majority of enrollees within the county was used. All premiums are displayed as the full price, rather than just the portion that covers essential health benefits.

The average changes in plan costs were weighted by county using 2018 plan selections obtained from the 2018 Marketplace Open Enrollment Period County-Level Public Use file provided by CMS, available here. In states running their own exchanges, we gathered county-level plan selection data where possible and otherwise estimated county plan selections based on the county population in the 2010 Census and total state plan selections in the 2018 OEP State-Level Public Use File provided by CMS, available here.

Endnotes
  1. The map legend shows premium changes in dollars rather than the percent change because, at the county level, percent changes may appear to overstate premium increases and understate decreases, particularly for those who qualify for relatively large premium subsidies. For example, a change from $60 to $2 is a -97% change but a change from $2 to $60 is a +2900% change. This issue is less prevalent when calculating the percent change in national average premiums, since outlier premiums are not given as much weight. The percent change in premiums by county can be viewed by hovering over the map.

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