Next Round of ACA Improvements Should Focus on Marketplace Cost Sharing

The Affordable Care Act (ACA) marketplaces provide comprehensive health coverage to millions of people, and recent enhancements to premium tax credits have made coverage more affordable than ever. However, many marketplace enrollees — like others with private insurance coverage — still struggle with unpredictable and high costs when they seek care. A new report produced as part of CBPP’s Marketplace Affordability Project (MAP) sheds light on these challenges and provides a vision, built on the strong foundation the ACA provides, for marketplace coverage that enrollees can afford to use.

Over the past year, CBPP has brought together approximately 40 participants in the MAP through a series of virtual meetings, focus groups, and one-on-one conversations aimed at identifying and addressing marketplace enrollees' most pressing health care affordability challenges. MAP participants included marketplace enrollees; people who provide marketplace application and enrollment assistance; patient groups; national groups representing specific racial, ethnic, disability, and age constituencies; and health policy experts.

MAP participants noted that the ACA significantly improved the availability and comprehensiveness of individual market coverage, but they also identified key pain points that affect marketplace enrollees’ access to health care and economic security. These included high deductibles, confusing coinsurance, narrow networks, and insufficient coverage for preventive care, primary care, and routine care for chronic and complex conditions. Participants described how the complexity of health insurance — both when people choose their plans and when they use their plans — is stressful for enrollees and can increase financial burden.

Many of these pain points will be familiar to people with other types of health insurance, especially those with employer-sponsored coverage. This project focuses on federal policy solutions that would reduce cost sharing for ACA marketplace enrollees, as Congress and executive agencies can use clear policy levers to implement these improvements. However, similar improvements could also be applied to other forms of private insurance coverage, and state policymakers could use additional levers to increase affordability.

The MAP report lays out specific policies to reduce or eliminate deductibles, shift from coinsurance to copayments, increase the generosity of marketplace plans, ensure robust coverage of preventive care and the ten Essential Health Benefits, reduce uninsurance, and minimize complexity. Each policy recommendation was informed by and reviewed by MAP participants, including marketplace enrollees, who described how these changes would improve their experience using their health insurance.

With enhancements to premium tax credits slated to expire in December 2025, much of the near-term attention on marketplace coverage will, rightfully, focus on the benefits of affordable premiums. Advancing health justice requires attention to not only people’s ability to get affordable coverage, but also their ability to use that coverage to access affordable care.

Policymakers should not lose sight of the importance of ensuring that marketplace enrollees, especially those with low incomes, can access needed care without incurring high out-of-pocket costs. The MAP report provides policymakers with a menu of options to begin doing just that.