Each year during open enrollment I get calls from family, friends, and even referrals from outsiders to help solve some of their perplexing insurance woes. I have tried to limit my so-called portfolio of free clients, but the caseload continues to be robust given the crushing affordability crisis. Here are a few of the cases I supported this year. At the end, I wil sum up and give you a feel for what changes need to be made to ensure all Americans gain affordable healthcare.
30-year-old graduate student with no employer sponsored coverage – good outcome individually but shows the huge inequity of the coverage gap as well as rising unaffordability
This person was on an Exchange Platinum plan in 2025 because of previous complex surgery and required follow-ups. As a student, the person was unsubsidized in the Exchanges for years because Florida did not expand Medicaid. No Exchange subsidies applied for persons below 100% of the federal poverty level (FPL) for income. This is a huge problem for students over 26 or whose parents do not have employer coverage.
This year, the person’s income changed. Because it exceeded100% of FPL, a premium subsidy in FL is now available. With surgery and follow-up done as well as few medications now to worry about, the person moved to a Silver plan. It made sense to move to Silver as the income allows the person to receive a special cost-sharing subsidy plan as well to limit potential out-of-pocket costs. The premium will now be about $275 after a $550 subsidy. The plan is more expensive than others due to one medication that is still needed (it is not furnished by cheaper plans or the monthly costs would be prohibitive) and the desire to maintain continuity of care with some physicians.
What is interesting is that the Platinum plan from 2025 surged from just under $900 per month to over $1,300 a month — a 40 plus percent increase. Thus, from one year to the next, the total cost of a Silver plan now rivals the cost of a Platinum plan the year before.
This story also shows the huge inequity of the coverage gap in ten states that have not expanded Medicaid and impacts millions of people. It needs to be addressed.
Mid-30s with a young dependent child – expiration of enhanced subsidies takes help away entirely.
The person received an Exchange premium subsidy for the family of two of about $500 per month for a Silver plan. The plan is more expensive than others in the caregory due to an important medication needed that is only available on some plans. It took months and months to get approval. The insurer has huge surges in premiums in 2026.
What’s more, income for the family increased and now puts the family over 400% of FPL. I had to explain that the enhanced subsidies are expiring (at least for now) and people over 400% of FPL no longer would get any subsidy. That means the family will have to pay over $1,660 per month for coverage in a Silver plan vs. the $500 per month in 2025.
How is it possible that a middle-income family can afford about $20,000 in premiums a year, even before deductibles and cost-sharing? I said that I hope some extension of enhanced subsidies will occur and that a special enrollment period might happen to get subsidized a bit again.
Two seniors on standalone Part D plans – lucky in an eroding program.
Premiums, deductibles, and cost-sharing are increasing dramatically in the standalone Part D (PDP) plans due to the impacts of drug costs, the effects of the cost-sharing reductions for some in the Inflation Reduction Act (IRA), and the financial challenges in the program in general. But if you search, you can still find low premium and low cost PDPs.
The first person in this category has numerous meds, but most are generic. Each year I search plans and move the person to the lowest total cost one I can find that covers the person’s meds. Because a few meds were removed by doctors this year, I was able to switch to a plan offered by the current insurer that saved several hundred a year. Luckily, the second person has few meds right now and always chooses a mid-level premium plan that still existed for 2026. The premium rose just a bit.
Unaffordability hits someone waiting to hit 65 and Medicare.
A retired, just-turned 64-year-old is waiting to turn 65 to solve an ongoing insurance dilemma. The person’s spouse is already on Medicare Advantage, but there is otherwise no retiree coverage for her. The person has been on the Exchanges for several years now since employer coverage ended. Given age, premiums in the Exchanges are extremely high.
While a premium subsidy is available, the family income is over 250% of FPL and no cost-sharing subsidies are available. As such, even the cheapest plans are expensive. The person had to settle for a Bronze plan again because a more comprehensive Silver one remains out of reach financially. The person is hoping that health remains good as the catastrophic nature of the Bronze plan would create major medical debt if a health issue came into play in 2026.
GLP-1 Medicare coverage questions – expansion not just yet.
The weight-loss craze is hitting younger Medicare eligibles. A number of seniors on Medicare have called me excited that GLP-1s are now covered more broadly in Medicare, including for obesity. I had to be a Grinch and tell them that is not exactly true. The plan and timeline are unclear. The president has announced his intention to make GLP-1 weight-loss drug coverage broader, but it has not yet taken effect and I doubt it will actually happen in 2026. If it does, it would only be a pilot for now, with perhaps broader coverage for all in 2027. Some folks are paying for their GLP-1 coverage out of pocket to the tune of $300 to $400 a month.
I told them to do the following:
- Look at various manufacturer sites soon to see if costs come down based on the drug price concessions obtained by the president.
- Search around compound pharmacies that are still making “personalized” prescriptions for GLP-1s.
- Keep an eye on Medicare for announcements.
- A few folks said they may have other underlying conditions outside of diabetes and heart disease, including sleep apnea, that may make them qualify now for coverage under Part D. I said discuss this with your doctor and health plan to see if coverage has been expanded on your plan’s formulary.
My dental situation – nothing compared to others but shows the complexity of coordination of benefits.
My wife and I are on a retiree health plan from a state employee retirement system. I was still obtaining dental and vision from my employer right now but was having huge issues coordinating coverage on some ongoing dental procedures between the employee plan (primary) and my retiree plan (secondary). Our dentist no longer bills two insurers, and it required us to file for reimbursement from my retiree dental plan – a huge headache with paperwork, calls, and more. At some points, we just stopped filing for reimbursement. My solution: I dropped my employee coverage so that my retiree coverage now is primary. It is a richer benefit plan that we can now take full advantage of.
Of course, I am blessed and this is a minor inconvenience compared with others who desperately worry about their coverage each day. And most do not even have dental coverage. But this final story points out the haves and have nots in American healthcare.
Summing up
As I said above, the crushing affordability crisis is hurting Americans each day. Costs throughout healthcare have been going up 6% to 9% annually over the past several years. Increases in employer coverage are especially robust. Researchers from Rice University and Baylor College of Medicine found that average worker contributions toward family insurance premiums grew by 308% between 1999 and 2024. Total premiums increased 342%, while average worker earnings increased by 119% and inflation increased by 64%. Healthcare policy group KFF found that the average cost of family coverage in the employer world is now $27,000 annually, with family’s paying almost $7,000 out of their paycheck before deductibles and cost-sharing begin.
In the Exchanges, KFF says the average hike in Exchange premiums was about 26% nationwide, but those numbers can vary by region and by the richness of the plan. Premiums for subsidized individuals will more than double when the enhanced premium subsidies expire.
Medicare Part B premiums will go up 10% next month, showing the huge spending hikes in the now $1 trillion beheamoth.
Root causes and what to do
There are a number of reasons for a lack of affordability:
- The community rating that was put into the individual market under the Affordable Care Act (ACA): This did indeed drive premiums and costs for some Americans up, especially for younger and healthier Americans. But I have argued the system is needed to address the plight of sicker folks who could not get insured under a medical underwriting system or premiums were to high. In fact, this type of rating system has been in the commercial world for years.
- The minimum essential benefits mandate under the ACA: This for sure has driven up costs. While prevention and robust coverage is good, there is no question that we need to relook at the richness of the ACA benefit and other mandates in general.
- Price: Most lawmakers, policymakers and the American public don’t talk about provider prices. They prefer to level charges at greedy health plans. But here is where the biggest cause of unaffordability lies. Prices in the American system are manyfold higher than those in other developed countries. A lot goes into it, but site neutrality, regional or national blended price schedules, and drug price reform could solve this issue – if lawmakers had the political backbone to tackle it.
- Rethink comprehensiveness: And while I am a fan of comprehensive coverage, it is time to rethink what we mean by this. Even with subsidies, richer and mandated benefits do not mean coverage in the truest sense if you cannot afford the policy or are essentially locked out of using your coverage once you pay the premiums. KFF finds in a poll that almost half of all Americans find it difficult to pay for needed coverage and over a third forego care due to costs. One in five forego needed prescriptions. And over four in ten have medical debt. It is time to explore alternatives that promote upfront primary care and disease state monitoring.
#healthcare #coverage #healthcarereform
— Marc S. Ryan
