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

While the percent of the population without health coverage has decreased substantially since the major coverage expansion in the ACA, about 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 2018, 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 2019. These subsidies also continue to make bronze plans more likely to be available for $0 than before cost-sharing reduction payments were terminated.

4.2 million uninsured people could get a bronze ACA plan for 2019 and pay $0 in premiums after factoring in tax credits. That’s 27% of the 15.9 million uninsured individuals who could shop in the Marketplace. Find out how many live in your state.

In this analysis, we focus specifically on the approximately 15.9 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 and those who are undocumented immigrants (who are not permitted to buy Marketplace coverage).

We estimate that 27% of uninsured individuals who could shop on the Marketplace, or 4.2 million people nationwide, are eligible to purchase a bronze plan with $0 premiums after subsidies in 2019. As shown on the map and table below, the availability of free bronze plans varies widely between states, from less than 5% of uninsured potential Marketplace shoppers in Washington and Indiana to more than 45% in Delaware, Iowa, Nebraska, and Utah.

Rather than continuing to go without insurance, the 4.2 million uninsured people eligible for $0 bronze plans would benefit from the financial protection health insurance offers. However, bronze plans have an average deductible of $6,258, and many people eligible for a $0 bronze premium would also be eligible for significant cost-sharing assistance by instead purchasing a silver plan.

On average in 2019, benchmark silver plans with cost-sharing reductions (CSR) for single individuals with incomes below 200% of the poverty level can be purchased for roughly $20 to $130 per month after subsidies, depending on an enrollees’ income.² Silver CSR plans have average annual deductibles ranging from $239 to $3,169 in 2019, 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

2019 Premiums come from Kaiser Family Foundation (KFF) analysis of premium data from Healthcare.gov and review of state rating filings. 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.

Data on population, income, and eligibility for subsidies come from KFF analysis of the Census Bureau’s 2017 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.

This analysis does not include individuals who are over the age of 65, or who are eligible for Medicaid in 2019 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.