'We Can't Afford to Get this Wrong' — The Hidden Costs of 'Fixing' the Marketplace

Proposed ACA reforms could unintentionally erode affordability and access, destabilizing the very marketplaces they aim to strengthen.

As Congress advances a sweeping Affordable Care Act (ACA) reform package, experts warn that the proposed fixes could unravel years of hard-won progress in access, affordability, and coverage stability.

These experts spoke as part of a June 11 KFF panel — How the Trump Administration and Congress Are Reshaping the Affordable Care Act’s Marketplaces: Views from the States — and included:

• Cynthia Cox, KFF vice president and director of its Program on the ACA
• Michele Eberle, executive director of the Maryland Health Benefit Exchange
• Pat Kelly, executive director of Your Health Idaho (also a state-based marketplace)
• Larry Levitt, KFF Executive Vice President for Health Policy

Introducing the panel, moderator Levitt summarized the impacts of the looming legislative and regulatory agenda — an estimated $793 billion in Medicaid cuts and another $268 billion in Marketplace premium assistance cuts, both over 10 years.

"At a trillion dollars in cuts in total, this would be the biggest rollback in federal support for health coverage ever," noted Levitt.

With final legislative votes looming, the panel urged Congress to pause and consider the downstream effects of the ACA reform package.

CSR appropriations: A fix that could break more than it solves

Some see cost-sharing reductions (CSRs) as the number one healthcare issue in the House’s "big, beautiful bill."

CSRs are federal subsidies that lower out-of-pocket costs for eligible low-income marketplace enrollees. Since 2017, following the Trump Administration’s abrupt decision to halt CSR payments to insurers, many states turned to a workaround known as "silver loading" — recouping the cost of unpaid CSRs on the backs of silver-tier plans and their enrollees

While silver loading began as a workaround, it has become integral to how the marketplace works — helping to increase overall premium subsidies, plan choices, and insurer stability.

"It's a little bit counterintuitive," says Cox of KFF. "But actually appropriating money and paying out the cost-sharing subsidies saves the federal government money relative to a scenario where insurance companies are charging a higher premium for silver plans."

Now, Congress is considering restoring CSR appropriations without protecting silver loading. This could raise net premiums and reduce plan choices for millions of marketplace enrollees.

"I think you'll see a little bit of a ripple effect," notes Idaho’s Kelly, adding: "You’ll have people dropping out. The first people that drop out are healthy individuals, so you’ll see a deterioration in the risk pool."

"It’s one more block of that Jenga tower being pulled out for 2026."

Expiration of enhanced tax credits: The looming affordability cliff

While the current package addresses CSR payments and silver loading, it leaves the future of enhanced subsidies uncertain. The scheduled expiration of enhanced premium subsidies at the end of 2025 — and their omission from current legislation — threatens an affordability cliff for low- and middle-income consumers.

Maryland’s Eberle noted: "Without any action from Congress, there's going to be a lot of confusion . . . How do we message that? How do we communicate? Because we know that our consumers who are used to auto enrollment will get that notice and be quite confused."

KFF’s Levitt added: "All told the Congressional Budget Office estimates that 10.9 million more people would be uninsured as a result of the Medicaid and ACA changes."

Cox concluded: "The enhanced premium tax credits expiring would change the net premium, meaning that people get less financial help, so they pay a larger share of the total premium."

This in turn, she added, would affect the Marketplace risk pool.

"We would expect that people who are sicker or higher risk would be more likely to keep their coverage . . . What that means is that on average, the people left in the market are sicker so that has the effect that insurance companies charge more for the premium."

Enrollment barriers: The quiet crisis of administrative complexity

Administrative barriers like pre-enrollment verification and underinvestment in marketplace infrastructure risk coverage losses come at a time when millions are transitioning from Medicaid.

Even as structural affordability is debated, a quieter crisis is unfolding in the form of enrollment barriers. One such barrier — pre-enrollment eligibility verification — has drawn concern for its unintended consequences.

Administrative complexity has long been an Achilles’ heel of public programs. Adding new hoops — no matter how well-intentioned — risks shrinking coverage gains, particularly for marginalized populations with limited time, resources, or digital access.

"I think the biggest issue will be if there's any additional barriers created for consumers who have for 12 years been auto-renewed in the process we've been using," noted Eberle.

"If that process changes and we're not able to communicate that effectively or they just don't expect it, then the outcome might be that someone loses that opportunity to enroll during the open enrollment period and may be locked out a coverage for another year."

"Newton’s Law" and the ACA: The unintended consequences are already in motion

Pat Kelly summed up the stakes by citing Newton’s Third Law: "For every action, there is an equal and opposite reaction."

Related to healthcare reform, Kelly cited the real-life tradeoffs families in his state could face.

"It means that a young family, a family of four here in the Treasure Valley, they

may have to choose between having health insurance or a soccer or travel team for their kids. Or we could have people in agriculture in the southeastern part of the state or up north where their income is more unpredictable. They could also have to make some really hard choices about investing in their agriculture business or choosing health insurance.

Adds Kelly: "I don't think for either of those situations, those are really good options."