Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, 5600 Fishers Ln, Mail Stop 07W41A, Rockville, MD 20857. Email:
Am J Manag Care. 2023 Jul;29(7):371-376. doi: 10.37765/ajmc.2023.89397.
Families with incomes above 400% of the federal poverty level were ineligible for marketplace premium tax credits before 2021 and may again be after 2025. Current laws temporarily removed this income cap, but because credits cap out-of-pocket premiums for a reference plan as a share of income, some higher-income families still receive zero tax credits. We quantified (1) premium differences between on- and off-marketplace plans and (2) the association between these premium differences and state decisions to finance cost-sharing reductions (CSRs) for lower-income families.
We created a comprehensive database of on- and off-marketplace plans in each county (including both federal and state-based marketplaces).
By county and metal level, we compared on- and off-marketplace (1) plan premiums in 2020 and (2) growth rates in the numbers of plans. We contrasted outcomes for states by how insurers were instructed to finance CSRs.
In 2020, 89% of the US population lived in counties where some plans were offered exclusively off-marketplace. In these counties, for a 45-year-old choosing among silver plans in 2020 and who did not qualify for premium subsidies, premiums for the lowest-cost off-marketplace plans averaged 11.3% less than premiums for the lowest-cost on-marketplace plans. In contrast, for bronze and gold plans, the lowest-cost off-marketplace plans were, on average, more expensive. Silver plan premiums were 6.1% higher off-marketplace than on-marketplace in states that loaded CSRs on all silver plans, and 13.5% lower in states that loaded CSRs only on on-marketplace silver plans.
Higher-income individuals and families may consider purchasing Affordable Care Act-compliant silver plans off-marketplace and thereby reduce their premiums. State and federal policy makers should consider the impact of their decisions on the choice between on- and off-marketplace plans.
在 2021 年之前，收入超过联邦贫困线 400%的家庭没有资格获得市场保费税收抵免，2025 年之后可能也没有资格获得。现行法律暂时取消了这一收入上限，但由于税收抵免将参考计划的自付保费上限设定为收入的一定比例，一些高收入家庭仍然没有获得任何税收抵免。我们量化了（1）市场内外计划之间的保费差异，以及（2）这些保费差异与各州决定为低收入家庭提供保费分担减免（CSR）之间的关联。
我们创建了一个包含每个县的市场内外计划的综合数据库（包括联邦和州级市场）。
按县和金属级别，我们比较了市场内外（1）2020 年的计划保费，以及（2）计划数量的增长率。我们根据保险公司被指示如何为 CSR 提供资金的方式来对比各州的结果。
2020 年，美国 89%的人口居住在某些计划仅在市场外提供的县。在这些县，对于一个 2020 年选择银级计划的 45 岁未获得保费补贴的人来说，最低成本的市场外计划的保费比最低成本的市场内计划平均低 11.3%。相比之下，对于青铜和黄金计划，最低成本的市场外计划的保费平均更高。在所有银级计划都加载 CSR 的州，市场外的银级计划保费比市场内高出 6.1%，而在仅在市场内银级计划加载 CSR 的州，保费低 13.5%。
高收入个人和家庭可能会考虑购买符合平价医疗法案的银级计划市场外，从而降低保费。州和联邦政策制定者应考虑其决策对市场内外计划选择的影响。
