In States Not Expanding Medicaid, Poor Are at Risk for Higher Costs, Fewer Benefits

The Commonwealth Fund

How Much Financial Protection Do Marketplace Plans Provide in States Not Expanding Medicaid?

The Affordable Care Act allows more people to get Medicaid, by expanding eligibility to people earning up to 138 percent of the federal poverty level—$16,243 for an individual and $33,465 for a family of four. However, the Supreme Court made the Medicaid expansion optional for states. As a result, 19 states have yet to expand eligibility for their Medicaid programs. In those states, people with incomes between 100 percent of poverty ($11,770 for an individual) and 138 percent of poverty are eligible to receive premium subsidies for private plans sold through the marketplaces (Exhibit 1). They also are eligible for lower deductibles and other cost-sharing assistance if they select silver tier plans.1 But people with lower incomes—below 100 percent of the poverty level—who live in states that have not expanded Medicaid are ineligible for these subsidies and would pay the full price for a marketplace plan.

This analysis focuses on the costs that people in nonexpansion states with incomes above 100 percent of poverty could potentially face for health insurance and health care and compares them to the costs a consumer might face in Medicaid. We use the example of a 40-year-old, nonsmoking man who earns $13,000 a year (about 110% of poverty) and chooses the second-lowest-cost silver plan in the largest city in each of the 18 nonexpansion states that use the federal website for 2016 marketplace enrollment.2 We used’s consumer cost comparison tool to provide a rough estimate of out-of-pocket costs.3 This brief builds on a prior Fund analysis, How Will the Affordable Care Act’s Cost-Sharing Reductions Affect Consumers’ Out-of-Pocket Costs in 2016? using a selection of health plans offered in the marketplaces in states that employ the federal website for 2016 enrollment.4


For someone earning about $13,000 annually, there are significant differences between the premiums and cost-sharing in Medicaid plans and those in marketplace plans. Overall, cost-sharing protections are greater in Medicaid as compared to marketplace plans.

Medicaid Premiums and Cost-Sharing

For Medicaid beneficiaries with incomes below 150 percent of poverty ($17,655 for an individual and $36,375 for a family of four), federal law prohibits charging premiums (Exhibit 2). Under Section 1115 waiver authority, however, the federal government has allowed five Medicaid expansion states (Arkansas, Indiana, Iowa, Michigan, and Montana) to charge premiums of 2 percent of income, or flat fees that range from $10 to $25 per month, to enrollees with incomes between 100 percent and 138 percent of poverty.5

Federal law also prohibits Medicaid premiums and cost-sharing for all individuals in a household from exceeding 5 percent of income, applied either on a monthly or a quarterly basis.9 For someone earning $13,000, this would amount to about $54 in a given month or $163 in a quarter, or about $650 a year whether the limit is applied monthly or quarterly. All states, including those with 1115 waivers, adhere to this cap (Appendix Table 1).

Marketplace Premiums and Cost-Sharing

In the marketplaces, premium contributions for people with incomes of $13,000 enrolled in the second-lowest-cost marketplace plan are capped at 2.03 percent of income. This amounts to about $22 per month, $66 in a quarter, or about $264 for the year.

People at this income level who are enrolled in silver plans also are eligible for cost-sharing reductions that increase the average share of costs covered by the plan—the so-called “actuarial value”—from 70 percent to 94 percent (Exhibit 1).

To reach this higher actuarial value, insurers can lower deductibles, copayments, and out-of-pocket limits. Plans use different combinations of these cost-sharing mechanisms and, as a result, we see variations across plans in deductibles (Exhibit 3), out-of-pocket limits (Exhibit 4), and copayments and coinsurance (Appendix Table 2). For plans with deductibles, there also was variation in the number and type of services excluded from the deductible. For such excluded services, enrollees do not have to pay the full cost even if they have not yet met their deductible.10

Comparing Coverage in Medicaid and Marketplace Plans

To determine whether Medicaid or marketplace plans provide better coverage for someone with an annual income of $13,000, we compare the benefits, premiums, and cost-sharing in two silver marketplace plans (in Houston, Texas, and Virginia Beach, Virginia) to traditional Medicaid. We also point out differences in the 1115 waiver states.

Traditional Medicaid overall offers greater financial protection in three major areas: the ban on premiums, the number of benefits covered, and overall limits on out-of-pocket spending (Exhibit 2).

Premiums. Our hypothetical consumer will pay no more than 2.03 percent of his income on premiums in the Houston and Virginia Beach plans, or about $22 per month. In contrast, with the exception of some 1115 waiver expansion states, he would pay nothing in premiums for Medicaid.

Covered benefits. The Affordable Care Act established benchmark coverage standards for Medicaid’s newly eligible adult population, as well as for qualified health plans sold in the health insurance marketplaces. These standards ensure that 10 categories of essential health benefits are part of the benchmark coverage for each market (Exhibit 5).11 But the benefits for newly eligible Medicaid enrollees exceed what is required in qualified marketplace plans.

In addition to the required benefits, a 2015 analysis by Sara Rosenbaum and colleagues found that most states enhanced their coverage by raising it to the level of coverage available under their pre-ACA Medicaid plan.12 This included supplemental drug coverage that is significantly higher than required under the essential health benefit standard for private plans.

Overall limits on out-of-pocket spending. The most important difference between marketplace plans and Medicaid is the out-of-pocket limit. Because cost-sharing and premium limits are applied on either a monthly or quarterly basis in Medicaid, beneficiaries have additional financial protection against large medical bills that might hit in a given month or quarter.13

For instance, let’s say our hypothetical consumer with Medicaid coverage experiences a health issue and spends the night in a hospital, resulting in a Medicaid bill of $3,000 for his stay and treatment. If the state Medicaid agency applies 10 percent cost-sharing on the service, his cost would come to $300. But with the Medicaid cost-sharing and premium limit, in a state that applies the cap on a monthly basis, an individual with an annual income of $13,000 could be charged no more than $54 (5% of $1,083 monthly income) for the service. A Medicaid enrollee with the same income living in a state that applied the cap on a quarterly basis could be required to pay no more than $163 (5% of $3,250 quarterly income).

In contrast, if the same person was enrolled in the Virginia Beach silver plan, he would first have to meet his $150 deductible and then be charged 10 percent of the remaining cost. Assuming the price of the inpatient stay is also $3,000, his total cost would come to $435,14 below his $600 out-of-pocket limit for the year. With his premium contribution of $22, his total spending for the month would be 42 percent of his monthly income. If he were enrolled in the Houston plan, he would be charged $300 at 10 percent coinsurance, which is substantially below his annual out-of-pocket limit of $2,250. With his premium contribution of $22 per month, he would spend $322, or 30 percent of his monthly income, on health insurance and care.

All six states that have expanded coverage under 1115 waiver authority apply the 5 percent cap on cost-sharing and premiums (Exhibit 2, Appendix Table 1). In addition, the monthly premiums or enrollment fees in Arkansas, Indiana, Michigan, and Montana can be used toward cost-sharing expenses; in Iowa, the premiums replace other cost-sharing obligations, except for nonemergency use of the emergency department starting in the second year of enrollment.15 Enrollees in Iowa, Indiana, and Michigan also can reduce their financial obligations through state healthy behaviors and wellness initiatives.16

How Much Will Our Consumer Spend in a Marketplace Plan vs. Medicaid?

Using’s cost comparison tool for our sample of plans in 18 states, we estimated costs for our hypothetical consumer.17 The premium contribution for someone with a $13,000 income is fixed for the second-lowest-cost plan at about $264 for the year; for a medium user of health care services, out-of-pocket costs ranged from $70 in Texas to $500 in Kansas (Exhibit 6).

Potential out-of-pocket costs in marketplace plans were higher for people with greater health care needs and reached the out-of-pocket limit in all the health plans analyzed. Out-of-pocket costs, not including premiums, ranged from $500 in the Kansas, Missouri, and North Carolina plans to $2,250 in the Texas plan (data not shown).18 Had the higher-use consumer enrolled in traditional Medicaid, and assuming that he hit Medicaid’s 5 percent spending cap every month or quarter (which would total about $650 a year), his overall costs would be lower than they would be in each of the 18 plans analyzed. This is partly because of Medicaid’s better cost protection and partly because he would not have to make a premium contribution.

The result is similar for someone who uses fewer services. For example, if our consumer is a medium-level user of health care and is enrolled in Medicaid—assuming the same level of utilization as and applying traditional Medicaid cost-sharing—his out-of-pocket costs for the year are approximately $148.19 His out-of-pocket costs for the year might exceed those he would incur in the silver marketplace plans in four states (Florida, Georgia, Mississippi, and Texas) (Exhibit 6). But because he would also pay a premium of $264 a year in a marketplace plan, his total costs for health insurance and care in traditional Medicaid would be less than in all 18 marketplace plans.


One major advantage of Medicaid over marketplace plans is that people with incomes under 138 percent of poverty do not pay a premium, except in the five 1115 waiver states that have gained federal approval to do so. Findings from The Commonwealth Fund’s tracking survey show that the primary reason people with low incomes do not enroll in marketplace plans is that they find the premiums unaffordable.20 Another critical advantage is that Medicaid’s cost-sharing protections recognize that people with low incomes have very little savings to tap into in the event of a major illness or accident.21 Private plans, even with cost-sharing subsidies, make no such adjustment to their out-of-pocket limits. A shift to traditional Medicaid expansion in the remaining 19 states will boost enrollment as well as provide greater cost protection for low-income families.

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