How ACA Marketplace Premiums Are Changing by County in 2020

Premiums for ACA Marketplace benchmark silver plans are decreasing on average across the U.S. in 2020. 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 falling in many areas of the U.S in 2020. This analysis has interactive maps with 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, state exchange websites, and healthcare.gov to see how premiums are changing at the county level both before and after subsidies in 2020. 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 (160% of poverty), $25,000 (200% of poverty), $30,000 (240% of poverty), $35,000 (280% of poverty), and $40,000 (320% of poverty), who would be eligible for a premium tax credit.

Figure 1[1]

Nationally, the average unsubsidized premium for the lowest-cost bronze, silver, and gold plans are decreasing by just under 3% from 2019 to 2020, and the average benchmark silver premium – on which subsidies are calculated – is dropping by somewhat more, about 3.5%. (Table 1).

Table 1: Change in the Average Lowest-Cost Premium by Metal Level Before Tax Credit, 2019-2020 for a 40-year-old
  2019 2020 % Change
Lowest Cost Bronze Premium  $340  $331 -2.6%
Lowest Cost Silver Premium  $454  $442 -2.7%
Lowest Cost Gold Premium  $516  $501 -2.9%
Benchmark Premium  $478  $462 -3.5%
 SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings.

In general, this could mean the tax credit covers somewhat less of the premium for subsidized enrollees who enroll in the lowest-cost plans. However, premium changes vary by geography, so whether enrollees will see their premium payments increase or decrease for 2020 will depend on how benchmark premiums are changing and how premiums for plans at their preferred metal level are changing in their county:

  • In Canadian County, Oklahoma, for example, unsubsidized premiums for benchmark silver plans are decreasing by 28%, while unsubsidized premiums for low-cost bronze plans are increasing 3%. This means that premium tax credits will cover less of the total premium for a low-cost bronze plan in 2020, and that bronze premium payments (after tax credits) will go up for subsidized enrollees.
  • Conversely, in Allamakee County, Iowa, unsubsidized benchmark silver premiums are increasing by 6% on average, while low-cost bronze plans are decreasing by 17%. In areas like this, where the gap between the benchmark plan and the lowest-cost bronze premium is growing, premium tax credits will cover more of the total premium for a low-cost bronze plan in 2020 and bronze premium payments (after tax credits) will go down for subsidized enrollees.

Premium changes for people eligible for subsidies will also be affected by changes in the amount they are expected to pay for a benchmark plan at any given income level, which is decreasing slightly in 2020.

Table 2: Change in the Average Lowest-Cost Premium by Metal Level After Tax Credit, 2019-2020
40-year-old with $20,000 income (160% of poverty) 2019 2020 % Change
   Lowest Cost Bronze Premium  $3  $2 -43.1%
   Lowest Cost Silver Premium  $60  $60 +0.1%
   Lowest Cost Gold Premium  $121  $118 -2.2%
40-year-old with $25,000 income (200% of poverty)
   Lowest Cost Bronze Premium  $26  $25 -5.3%
   Lowest Cost Silver Premium  $118  $117 -0.8%
   Lowest Cost Gold Premium  $180  $177 -1.8%
40-year-old with $30,000 income (240% of poverty)
   Lowest Cost Bronze Premium  $76  $75 -1.4%
   Lowest Cost Silver Premium  $183  $180 -1.7%
   Lowest Cost Gold Premium  $245  $239 -2.3%
40-year-old with $35,000 income (280% of poverty)
   Lowest Cost Bronze Premium  $142  $140 -1.2%
   Lowest Cost Silver Premium  $253  $249 -1.7%
   Lowest Cost Gold Premium  $315  $308 -2.2%
40-year-old with $40,000 income (320% of poverty)
   Lowest Cost Bronze Premium  $191  $197 +2.8%
    Lowest Cost Silver Premium  $304  $307 +0.8%
   Lowest Cost Gold Premium  $366  $366 0.0%
 SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings.

As was the case in 2018 and 2019, 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 the dollar amount may be somewhat smaller than in past years 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 $20,000 covers the full cost of the premium for the lowest-cost bronze plan in 85% of counties (2,661 out of 3,142 counties in the U.S.). This is similar to 2019, when the tax credit has covered the full cost of the lowest-cost bronze plan for a low-income enrollee in 81% of counties (2,547 counties).

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 2019 2020
40-year-old with $20,000 income (160% of poverty) 2,547 (81% of counties) 2,661 (85% of counties)
40-year-old with $25,000 income (200% of poverty) 2,028 (65%) 1,736 (55%)
40-year-old with $30,000 income (240% of poverty) 661 (21%) 608 (19%)
40-year-old with $35,000 income (280% of poverty) 410 (13%) 287 (9%)
40-year old with $40,000 income (320% of poverty) 120 (4%) 135 (4%)
SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings.  

However, even if subsidized 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 $2,700, and the deductible would 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 $8,150. 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.

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 (160% of poverty), $25,000 (200% of poverty), $30,000 (240% of poverty), $35,000 (280% of poverty), and $40,000 (320% of poverty).

Figure 2

For subsidized enrollees, a gold plan may actually be available at no cost after tax credits are applied as well (Table 4). For example, the tax credit for a 40-year-old individual making $20,000 covers the full cost of the premium for the lowest-cost gold plan in 240 counties (out of 3,142 counties in the U.S.). This is a decrease from 2019, when the tax credit covered the full cost of the lowest-cost gold plan in 392 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 2019 2020
40-year-old with $20,000 income (160% of poverty) 392 (12% of counties) 240 (8% of counties)
40-year-old with $25,000 income (200% of poverty) 153 (5%) 207 (7%)
40-year-old with $30,000 income (240% of poverty) 39 (1%) 87 (3%)
40-year-old with $35,000 income (280% of poverty) 12 (0.4%) 35 (1%)
40-year old with $40,000 income (320% of poverty) 12 (0.4%) 12 (0.4%)
SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings.  

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 2020, before tax credits are applied.

Figure 3

 

Discussion

With news of average benchmark premiums dropping a bit on average in 2020, 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 some 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 benchmark silver plans in 2020 continue to have relatively higher costs compared to bronze plans, low-income 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 many counties in 2020 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 the federal government 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 and much higher value than bronze 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 2019 and 2020 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 13 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. Premiums for California and Massachusetts were collected at the zip code level, and premiums for Washington and Nevada were collected at the county level. 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 2019 plan selections obtained from the 2019 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 2019 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.