Five Things to Know about the Possible Renewal of Extra Affordable Care Act Subsidies

Five Things to Know about the Possible Renewal of Extra Affordable Care Act  Subsidies | KFF

Source: Kaiser Family Foundation, by Cynthia Cox, Krutika Amin, and Jared Ortaliza

Congress is considering an extension of extra help for people buying their own health coverage on the Affordable Care Act Marketplaces. These temporary subsidies, passed as part of the American Rescue Plan Act (ARPA), increased the amount of financial help available to those already eligible; the ARPA also newly expanded subsidies to middle-income people, many of whom were previously priced out of coverage.

There are reports Congress is considering a temporary extension of the subsidies for two years. If these subsidies expire, either at the end of this year or after a temporary renewal, premium payments will rise. Here’s what to know:

The Big Picture: How Much Higher Would Premium Payments be Without ARPA?

If Congress extends the temporary subsidies, premium payments in 2023 will hold mostly flat for Marketplace enrollees, since the premium tax credits shelter enrollees from increases in the underlying premium. However, if these extra subsidies expire, out-of-pocket premium payments will rise across the board next year for virtually all 13 million subsidized enrollees. In the 33 states using, premium payments in 2022 would have been 53% higher on average if not for the ARPA extra subsidies. The same is true in the states operating their own exchanges.

Exactly how much of a premium increase enrollees would see if these subsidies expire depends on the enrollee’s income, age, and the premiums where they live.

For example, using our subsidy calculator, you can see that with the ARPA a 40-year-old couple making $25,000 per year currently pays $0 for a silver plan premium with significantly lowered out-of-pocket deductible costs. Using a new version of our subsidy calculator that shows what premium payments in each zip code would have been if the ARPA had not passed, you can see that same couple would have paid $76 per month (or $915 over the course of 2022) without the ARPA. If Congress extends the ARPA subsidies, though, this low-income couple would save $915.

Here’s another example using the new calculator: If the ARPA hadn’t passed, a 60-year-old couple with an income of $70,000 would have had to pay $1,859 per month (or $22,307 over the course of 2022) for a full-price silver plan. Now, compare this to our 2022 calculator that shows what they currently pay with the ARPA: The same couple currently pays $496 per month (or $5,950 over the course of the year). Instead of being expected to pay about 32% of their income on insurance, which would likely be unaffordable, the couple is paying 8.5% of their income with the ARPA. So, if Congress extends the ARPA subsidies, this older middle-income couple will save over $16,000.

The Double Whammy: How 2023 Premium Increases and Subsidy Expiration Would Affect Some Enrollees

The renewal of these subsidies would also prevent some enrollees from experiencing two kinds of premium increases at once. If Congress does not extend these subsidies, the subsidy cliff would return, meaning people with incomes over four times poverty (or about $51,520 for a single person) would lose subsidy eligibility altogether. So, without the ARPA subsidies, these enrollees would not only pay the increase due to the loss of subsidies, but also any increase in the underlying premium.

Our early look at 2023 premiums shows premiums rising about 10%, with most rate increases falling between about 5% and 14%. This is more than in past years, in part due to inflation and rebounding utilization. These rates are still proposed and will not be finalized until next month.

The figure below shows a hypothetical subsidy cliff if premiums do indeed rise by 10%. For example, a 60-year-old making just above four times poverty ($51,521) in 2022 pays 8.5% of their income on a silver plan under ARPA, but would have paid 22% of their income in 2022 without the ARPA on average across the U.S. If premiums rise 10%, they would pay 24% of their income in 2023.

In the states where premiums are currently highest, people losing subsidies would see the steepest increases without the ARPA subsidies. For example, a 60-year-old making just above four times poverty ($51,521) in 2022 would pay more than a third of their income on a silver plan without the ARPA in West Virginia and Wyoming; and in New Hampshire, the person would have paid 15% of their income without ARPA.

The Ticking Clock: Why the Timing Matters

Insurers are now in the process of setting 2023 premiums and some are already factoring in an additional premium increase because they expect ARPA subsidies to expire.

The National Association of Insurance Commissioners (NAIC) wrote to Congress asking to extend these subsidies by July to provide greater certainty as insurers set premiums for next year. Premiums for 2023 are locked in by this August, so if Congress does not act before its August recess, whatever assumptions insurers make about the future of ARPA subsidies will be factored in to their 2023 premiums.

States and the federal government, which operates, will need to reprogram their enrollment websites and train consumer support staff on policy changes months ahead of open enrollment this fall. If Congress ultimately extends the enhanced ACA subsidies but does not give state and federal exchange administrators enough lead time to make changes to enrollment websites, people shopping for coverage may get incorrect information or may temporarily lose access to subsidies, causing some to drop coverage.

The End of the Public Health Emergency: How Enhanced Marketplace Subsidies Could Mitigate Coverage Loss

The end of the public health emergency and, with it, the requirement for continuous enrollment in Medicaid is expected to lead to significant coverage losses. So far, the number of uninsured people has not grown during the pandemic and resulting economic crisis. However, ironically, we could see a jump in the uninsured rate as the public health emergency ends if people disenrolled from Medicaid do not find alternative coverage.

Enhanced Marketplace subsidies could act as a bridge between Medicaid and the ACA Marketplaces when the public health emergency ends. If enhanced Marketplace subsidies are still in place when the Medicaid maintenance of eligibility (MOE) ends, many people disenrolled from Medicaid could find similarly low-cost coverage on the ACA Marketplaces. If they are eligible for Marketplace subsidies, people losing Medicaid coverage may find Marketplace plans that, like Medicaid, have zero (or near-zero) monthly premium requirement, assuming the enhanced assistance is extended.

The Costs: What This Means for the Federal Budget

The Congressional Budget Office (CBO) expects the enhanced subsidies to cost about $248 billion over the course of ten years if extended permanently. A large part of the estimated cost is due to the CBO’s expectation that 4.8 million more people would enroll in the ACA Marketplaces than would if the enhanced subsidies are not extended. The actual cost will depend on how many people enroll and how much premiums rise over the coming years. Congress could lower the total cost by extending subsidies temporarily, for example by two or three years, but the annual cost would likely stay about the same.


Health sector inflation, rising utilization, and other factors may cause 2023 premiums to rise by more than in past years. However, as we’ve written before, Congress’s action or inaction on ARPA subsidies will have an even greater influence over how much subsidized ACA Marketplace enrollees pay out-of-pocket for their premiums than will market-driven factors that affect the underlying premium.

Whether subsidies expire at the end of this year or in two or three years, their expiration would result in the steepest increase in out-of-pocket premium payments most enrollees in this market have seen.

CHIP renewal, court ruling affect coverage for nearly 2M children

An Urban Institute report predicts that 1.9 million children would lose coverage if Congress decides not to reauthorize the Children’s Health Insurance Program and if the Supreme Court rules against Affordable Care Act subsidies. “The combination of both policies would mean a lot of progress we’ve made over the last 20 years would be wiped out,” Urban Institute senior fellow Lisa Dubay said. The Hill (3/18), Modern Healthcare (tiered subscription model) (3/18)

Covered California Launches Renewal Initiatives

RenewalCoveredCACovered California has begun the renewal process for 1.12 million people who enrolled in plans in the exchange last year. Open enrollment will begin Nov. 15 and continue through February 15. Open enrollment is the next opportunity for all Californians to benefit from new insurance rules, including the requirement that insurance be offered regardless of health status. In addition, Californians can buy subsidized coverage starting in 2015. Consumers who complete the renewal process will hear from their insurance plans in December. Their selected health plan will send a statement reflecting coverage starting January 1, 2015. Consumers who take no action will be renewed into their existing plan. More than 12,000 certified insurance agents, 10,000 county eligibility workers, and 6,400 certified enrollment counselors will help enroll consumers.

People who have health coverage through Medi-Cal can renew their coverage throughout the year, on a rolling monthly schedule. Medi-Cal will contact them directly if they need to take action. Unless they are contacted by Medi-Cal, these people don’t need to go to the Covered California website to renew or apply.

Covered California also provided updated enrollment numbers for 2014. Eighty-one percent of Californians who selected a plan during the initial open enrollment had their coverage take effect by paying their first month’s premium. A total of 1.12 million people have coverage and will be part of the renewal process. Covered California expects this number to increase with about 1.3 million Californians participating in the renewal process through the end of the year.

“This is our very first experience with renewal, and we will learn things during this process just as we learned a great deal about open enrollment during 2013 to 2014. We do believe many significant improvements have been made that will assist our consumers during renewal and open enrollment this year. We know this open-enrollment period will be more challenging in some ways. Consumers will only have three months to enroll, compared with the six months they had last time. This is complicated by our knowledge that many who are uninsured have adapted to a culture of coping and have become accustomed to living without health insurance,” said Covered California executive director Peter Lee.

Covered California will start open enrollment with more than double the number of service center representatives — state employed and contractors — to dramatically reduce wait times and help consumers enroll. More than 1,300 representatives will help consumers over the phone, by chat or by processing their paper applications or documents. This year, Covered California will have 254  reps who can serve consumers in languages other than English, compared to 55 in 2013. Covered California is working with health plans to make it possible for consumers to make their first premium payment online as soon as they have selected a plan. This will give consumers evidence that their payment has been received and that they will have coverage in place.

Covered California is redesigning its interactive voice response (IVR) system to handle more consumer calls while reducing wait times. With less than one month before open enrollment begins, consumers can begin the process of shopping for 2015 coverage. They can find out if they are eligible for financial assistance and find out how much a health plan will cost them, by using Covered California’s Shop and Compare Tool (on at Covered California also offers a full listing of the plans and their rates at

New rule auto-enrolls ACA coverage renewal

Proposed federal rules would allow automatic re-enrollment in health insurance plans purchased via Affordable Care Act exchanges. The development is expected to ensure more continuity of coverage for enrollees, as occurs with employer-sponsored insurance. Bloomberg (6/27)

Last Updated 08/10/2022

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