Health of the ACA Health Insurance Markets

ACA failed to deliver lower healthcare costs, but states can take the lead

Preview:

The data makes clear that the Affordable Care Act has failed to reduce healthcare costs and Medicaid expansion has worsened outcomes in many markets by distorting risk pools. This may be exacerbated further in states with a Basic Health Program, like Minnesota, which posted higher average rate increases in 2025 in both the individual and small group market than the U.S. average. If states want to make a meaningful difference in lowering premiums and benefit costs, they must pursue reforms that improve risk pools, strengthen accountability, and empower patients.

This report, Health of the ACA Health Insurance Markets, reviews annual CMS rate review data between 2015 and 2023. We first examine enrollment trends to understand who is in the ACA risk pools. Then, we examine premiums and benefits costs to trace how expenses for patients and insurers have grown far faster than inflation. Our examination of rate increases and silver loading highlights how the structure of the ACA marketplaces has further distorted prices. We conclude by highlighting state solutions that could lower healthcare costs for patients, increase competition in stagnant markets, and protect taxpayers from runaway spending.

A full copy of the report can be viewed here.