One provision of the Patient Protection and Affordable Care Act of 2010 created what are commonly known as the “Marketplaces,” which are health insurance exchanges run at the state level, intended to allow those with medium and low incomes to purchase health insurance with the aid of federal subsidies? How are they working out?
Drew DeSilver provides a fact-based overview in “What the data says about Affordable Care Act health insurance exchanges” (Pew Reseach Center, January 22, 2026). Before the pandemic, the exchanges were a mechanism for health insurance coverage for about 10 million people. During the pandemic in 2021, Congress and President Biden passed into law a substantial expansion of the subsidies, and the number of people receiving insurance through the Marketplaces more than doubled to 23 million. “Data from the Centers for Medicare & Medicaid Services shows that the government spent $116.6 billion on marketplace tax credits and subsidies in the 2024 calendar year.” The additional subsidies enacted in 2021 had been scheduled to sunset at the end of 2025, and after considerable political acrimony, they did so.

Here is DeSilver’s quick overview of the health insurance offered by these plans:
All plans sold on ACA exchanges have to cover a set of “essential health benefits,” though the precise services vary by state.
As in the regular insurance market, exchange plans can have different premiums, deductibles, copayments, covered services and reimbursement rates. To help consumers sort through all that, exchange plans are sorted into four tiers, based on how much of patients’ covered health care costs they pay on average (that is, not for any specific customer or claim):
- Platinum: 90% of costs covered, on average
- Gold: 80%
- Silver: 70% (or possibly more depending on income)
- Bronze: 60%
In general, Platinum and Gold plans have the highest premiums and lowest deductibles, while Bronze plans have the lowest premiums and highest deductibles. There also are “Catastrophic” plans, with very low premiums and very high deductibles, but they’re only available to certain people. Fewer than 1% of exchange customers opt for Catastrophic plans.
In some cases, people who choose Silver plans – but no others – can get extra federal subsidies that lower their copayments and other out-of-pocket costs. Those subsidies, which are known as “cost-sharing reductions” and vary depending on income, can raise Silver plans’ payout shares to as much as 96%. Perhaps for that reason, Silver plans are by far the most popular. More than half (56%) of all plans selected on all exchanges during the pre-2025 open enrollment period were Silver …
In 2021, Congress made the premium tax credits more generous and made more people eligible for them. Before these changes, the required contribution percentages ranged from 2.07% to 9.86% of income. Afterward, they ranged from zero percent to 8.5%. The law also extended subsidies to people whose income exceeded 400% of the federal poverty level (which itself varies by household type). Previously, 400% was the upper limit.
Thus, some key questions include to what extent the failure to renew the additional federal subsidies added in 2021 will affect the number of people without health insurance, how much money will the government save, and the extent to which the spike in Marketplace enrollment came from people not actually eligible for the program. The Bipartisan Policy Center summarizes a rang of evidence on these points in “Enhanced Premium Tax Credits: Who Benefits, How Much, and What Happens Next?” (Octover 15, 2025).
It cites estimates that that the decision to extend the 2021 subsidies by a year, though 2026, would have led to to 2.0 million more people with health insurance. As noted a moment ago, because the subsidies already reached people up to 400% of the povert line in some states, and higher after 2021, many of those losing health insurance would have incomes above the poverty line. Extending the subsidies by a year would also have increased the federal deficit by $23.4 billion. Long division tells me that extending the 2021 expandion of benefits through 2026 would have led to an 2 million people with health insurance at an average cost to the federal goverment of $11,000 per person.
In addition, the Congressional Budget Office estimated that about 1.3 million of those receiving health insurance subsidies were not, in fact, eligible for them. The subsidies depend on income reported, but the specific amount of income that makes one eligible for subsidies varies across states. The CBO conclusion is based on observing that the share of people reporting the specific income levels that made them eligible for health insurance subsidies–for example, in many states, income between 105-110% of the poverty level–was much higher in the states where this level of income was necessary to receive the subsidy.
My own sense is that before the pandemic, the state-run health insurance marketplaces were working better than many of their critics had expected. However, a number of the policies enacted in haste during the pandemic deserve reconsideration, and the 2021 expansion that more than doubled the program size is one of them. I hold out no particular hope that a careful reconsideration is politically possible, but research in the next year or two may offer some guidance.









