Individual market health plan affordability after cost-sharing reduction subsidy cuts

Coleman Drake, Jean M. Abraham

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


Objective: To investigate how changes in insurer participation and composition as well as state policies affect health plan affordability for individual market enrollees. Data Sources: 2014-2019 Qualified Health Plan Landscape Files augmented with supplementary insurer-level information. Study Design: We measured plan affordability for subsidized enrollees using premium spreads, the difference between the benchmark plan and the lowest cost plan, and premium levels for unsubsidized enrollees. We estimated how premium spreads and levels varied with insurer participation, insurer composition, and state policies using log-linear models for 15 222 county-years. Principal Findings: Increased insurer participation reduces premium levels, which is beneficial for unsubsidized enrollees. However, it also reduces premium spreads, leading to lower plan affordability for subsidized enrollees. States responding to cost-sharing reduction subsidy payment cuts by increasing only silver plans' premiums increase premium spreads, particularly when premium increases are restricted to on-Marketplace silver plans. The latter approach also protects unsubsidized, off-Marketplace enrollees from experiencing premium shocks. Conclusions: Insurer participation and insurer composition affect subsidized and unsubsidized enrollees' health plan affordability in different ways. Decisions by state regulators regarding health plan pricing can significantly affect health plan affordability for each enrollee segment.

Original languageEnglish (US)
Pages (from-to)730-738
Number of pages9
JournalHealth services research
Issue number4
StatePublished - Aug 2019

Bibliographical note

Funding Information:
to acknowledge the constructive comments provided by the edi‐ tors and anonymous reviewers. Support for this research was pro‐ vided by the Robert Wood Johnson Foundation under grant award #75027. The views expressed here do not necessarily reflect the views of the Foundation. Disclosures: None. Disclaimer: None.

Publisher Copyright:
© Health Research and Educational Trust


  • Affordable Care Act
  • Health Insurance Marketplace
  • health insurance


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