How Many of the Uninsured Can Purchase a Marketplace Plan for Free in 2020?

While the percent of the population without health coverage has decreased since the major coverage expansion in the ACA, at least 10% of the non-elderly population is still uninsured. This analysis looks at how many of the remaining uninsured are eligible for premium subsidies large enough to cover the entire cost of a bronze plan, which is the minimum level of coverage available on the Marketplaces.

The premium tax credits that subsidize Marketplace coverage are calculated using the second-lowest cost silver plan in each rating area as a benchmark. As was the case in 2019, many unsubsidized silver plans continue to be priced relatively high 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 means subsidy-eligible Marketplace enrollees will continue to receive large premium tax credits in 2020. These subsidies – which can be used towards the premium of any Marketplace plan – also continue to make lower premium bronze plans more likely to be available for $0 than before cost-sharing reduction payments were terminated.

In this analysis, we focus specifically on the approximately 16.7 million uninsured people who could be shopping on the Marketplace, regardless of whether or not they are eligible for a subsidy.¹ We therefore exclude people who are eligible for Medicaid, those over the age of 65, and those who are undocumented immigrants (who are not permitted to buy Marketplace coverage).

We estimate that 28% of uninsured individuals who could shop on the Marketplace, or 4.7 million people nationwide, are eligible to purchase a bronze plan with $0 premiums after subsidies in 2020. This figure is similar to 2019, when 27% of uninsured individuals, or 4.2 million people, could purchase a no-premium bronze plan.

As shown on the map and table below, the availability of free bronze plans varies widely between states. More than half of the uninsured who could get a free bronze plan live in Texas, Florida, North Carolina, or Georgia. Other states with large shares of uninsured residents who could sign up for a no-premium bronze plan include Iowa (59%), Alaska (45%), Wyoming (44%), Idaho (41%), and South Dakota (41%).

Rather than continuing to go without insurance, the 4.7 million uninsured people eligible for no-premium bronze plans would benefit from the financial protection health insurance offers. While bronze plans have high deductibles, they all cover preventive care with no out-of-pocket costs, and a number of bronze plans cover additional services, such as a few physician visits, before the deductible. If a low-income enrollee in a bronze plan needs a hospitalization, they will likely have difficulty affording the deductible, but the deductible will also likely be much less than the cost of a hospitalization without insurance.

Bronze plans have an average deductible of $6,506, and many people eligible for a $0 bronze premium would also be eligible for significant cost-sharing assistance by instead purchasing a silver plan. Single individuals with incomes below 250% of the poverty level can purchase benchmark silver plans with cost-sharing reductions (CSR) for $20 to $215 per month after subsidies in 2020, on average, depending on an enrollees’ income. Silver CSR plans have average annual deductibles ranging from $209 to $3,268 in 2020, also depending on income, and have reduced copays and coinsurance. It is therefore important for potential enrollees, particularly those with significant health needs, to not only consider the premium, but also the significant cost-sharing assistance that is only available if they enroll in a silver plan.

Methods

2020 Premiums come from Kaiser Family Foundation (KFF) analysis of premium data from Healthcare.gov and review of state rating filings. Data on population, income, and eligibility for subsidies come from KFF analysis of the Census Bureau’s 2018 American Community Survey (ACS). The ACS includes a 1% sample of the US population and allows for precise state-level estimates. The ACS asks respondents about their health insurance coverage at the time of the survey. Respondents may report having more than one type of coverage; however, individuals are sorted into only one category of insurance coverage.

Premiums in this analysis are the full price of plans, rather than specifically the portion that covers essential health benefits (EHB). Since premium tax credits can only be used to cover the EHB portion of premiums, some of the individuals denoted as having access to a “free” bronze plan would actually have to pay a premium for non-essential health benefits if they enrolled in a bronze plan. The ACA does not permit federal subsidies to pay for abortion coverage and requires plans to collect no less than $1.00 per month for this coverage. In CA, IL, NY, ME, OR, and WA, state law requires that that all state regulated plans include abortion coverage. Policyholders who live in these states must pay the abortion surcharge even though they may qualify for subsidies that provide the full cost of premiums if they select a bronze plan. Providence Health Plans in OR and WA have a religious exemption allowing them to exclude abortion coverage.

This analysis does not include individuals who are over the age of 65, or who are eligible for Medicaid in 2020 or are undocumented immigrants. DC is not included in this analysis due to an insufficient sample size in the ACS. New York and Minnesota are not included in this analysis because they offer Basic Health Plans to enrollees with incomes less than 200% of poverty.