New analysis from the Kaiser Family Foundation demonstrates that getting health insurance isn't just a problem for the working poor. Solidly middle-income people, particularly older and rural folks, are facing significant financial barriers in getting individual insurance on the Affordable Care Act and off-exchange markets. These are the 3.9 million—down from 8.7 million in 2015—who make too much in income to qualify for premium assistance in the ACA.
The subsidy structure for the ACA cuts off federal assistance for premiums at incomes at 400 percent of the poverty line, or nearly $49,000 for an individual and just over $100,000 for a family of four. Up to that point, people buying on the ACA market can get subsidies. Beyond that, they disappear, lending the phenomenon the name "subsidy cliff." KFF uses this example: "On average across the U.S., a 40-year-old making $45,000 would pay $227 a month (6% of their income) for a subsidized bronze exchange plan, whereas the same person making $50,000 would pay $340 a month (8% of their income) for the same plan without a subsidy."
It's even worse if you're older: "a 27-year-old making $50,000 would pay 7% of their income in premiums for the average lowest-cost plan nationally, whereas a 60-year-old making the same income would pay 17% of their income in premiums. Even at an income of $70,000 (577% of the poverty level), a 60-year-old would have to pay 12% of income for a low-cost plan on average." It's also worse for residents of rural areas, where health plans tend to be more expensive. They take the example of a 60-year-old in almost any county in Nebraska, making $50,000 in income and paying between 30 percent and 50 percent of their income in premiums. And that's for the least expensive, ACA-compliant plans.
Those bronze-level plans were used for the whole analysis, and KFF points out that beyond those eye-popping premium levels, the plans have high deductibles and out-of-pocket expenses for enrollees. These costs can be high enough for people even with average medical use to make it more affordable for them over a year's time to go with a higher premium plan.
Eliminating the subsidy cliff altogether is one option, and an expensive one. Increasing the allowable income is another, but the level would have to be included to 1,4000 percent of the poverty level for a single 64-year-old in 28 of Nebraska's counties to pay just 10 percent of their income for a bronze plan. What makes the most sense at this point for this population is the quick fix of expanding Medicare to age 50.
That quick fix isn't coming, though, not with a Republican Senate and Trump in the White House. Should it be a top priority for Democrats if they retake both in 2020? Absolutely, along with implementing Medicare for All and dealing with all of the issues of access to health care in our country.