How to Increase the Generosity of Marketplace Plans Under the Affordable Care Act (ACA)

The Affordable Care Act (ACA) has reduced the number of uninsured Americans to historically low levels and helped millions of people access health care services. However, many people struggle to afford the health insurance premiums and cost sharing required by ACA.

To address this, the ACA provides assistance to help make marketplace plans more affordable for those with incomes below 250 percent of the federal poverty line. These reductions in cost sharing are known as “cost-sharing reductions” or CSRs. The ACA also requires that marketplace plans offer coverage for essential health benefits (EHBs) that are comparable to the benchmark plan. The EHBs include doctor and hospital visits, prescription drugs, mental health and addiction care, pregnancy and childbirth, preventive care, and more. The ACA allows each state to determine which specific services qualify as EHBs by selecting or designing an “EHB benchmark plan.” Individual and small group marketplace plans are required to offer coverage that is “substantially equal” to this plan.

One way that Congress could increase the generosity of marketplace plans is by modifying the actuarial value (AV) standards used to set cost-sharing charges. The AV of a plan establishes the percentage of total costs a marketplace plan must cover and the percentage that it passes on to enrollees for a standard population. The AV of each marketplace plan is determined by HHS using an enrollee’s risk score, which is based on a variety of demographic factors such as age, their plan metal tier and the likelihood that they will use health services.

Another way to increase the generosity of marketplace plans is to require that they provide monthly caps on out-of-pocket maximums. This would replace the current annual cap on out-of-pocket spending and more closely align with how individuals pay their health care bills. A cap could also help reduce the costly “cost-sharing peaks” that occur when people incur expensive medical bills and are still undergoing treatment for an illness or injury.

Finally, the ACA prohibits insurers from discriminating against or rescinding coverage of an enrollee due to their health status. Prior to the ACA, a person’s health status could make their premiums so high that they were unaffordable or even impossible to purchase on the individual market. This provision was the catalyst for the infamous (and unsubstantiated) Republican fear of “death panels” that helped contribute to the ACA’s deletion from the bill in January 2011.

The ACA has also enabled more than 30 million young adults to have access to affordable health insurance through their parents’ plans until they turn 26. This is an important protection, and it is crucial that Congress not allow these expanded family-based coverage options to lapse. To avoid the loss of these vital protections, the ACA needs to be strengthened and expanded. We encourage you to join us in supporting these bipartisan proposals. Together, we can ensure that the ACA continues to lower health costs for families and expands the availability of coverage to all Americans.